Rapid Fire Morning Report - ACS, Hypertensive Urgency, Dementia, and Eating Disorders

Today, we had the first Rapid Fire or Post-Call Morning Report at Toronto General Hospital since 2013!  For those familiar with this in other hospitals, the goal of this type of morning report is to discuss high-level management issues regarding a number of the patients referred overnight.  Rather than focusing on a single case more from a diagnostic perspective, we focused on several cases with valuable teaching points and more of a management perspective. 

There were multiple learning points:

-We don’t see a lot of patients with acute coronary syndromes on the medicine service as many of these patients go to cardiology.  The first patient was a patient with previously documented coronary disease and acute coronary syndromes, who presented with chest discomfort not unlike prior MI’s.  The pain began at rest and resolved at rest, but was otherwise relatively typical in character.  The patient was treated as a NSTEMI.  We discussed the role of Clopidogrel (Plavix®) in this situation.  The original CURE trial would have only recommended clopidogrel in very high risk situations.  The latest AHA 2014 guidelines, however, do recommend dual antiplatelet (ASA and clopidogrel) in all patients with NSTEMI for 12 months regardless of management strategy.  New players in the dual antiplatelet market are Ticagrelor (Brilinta®) and Prasugrel (Effient®).  These drugs are recommended in lieu of clopidogrel if PCI and stenting is likely, or if patients are presenting with an ST-segment elevation event.  They are much more effective antiplatelets than clopidogrel.  In addition to ASA and a second antiplatelet, the 2014 AHA guidelines recommend that all patients receive anticoagulation with a  low molecular weight heparin, unfractionated heparin, or fondaparinux (helpful here because it’s the lower DVT prophylaxis dose) for the duration of the hospitalization, or until PCI is performed.

-We talked briefly about hypertensive urgency and emergency.  The case involved a woman with a bloodpressure of 220/110mmHg.  There are no definite blood pressure cutoffs for urgency vs. emergency.  The usual way of distinguishing them is whether end-organ damage is present.  This would include hemorrhagic stroke, aortic dissection, flash pulmonary edema, chest discomfort or a demand-related troponin elevation, acute kidney injury from hypertension, limb ischemia, etc.  If emergency is present, this usually warrants ICU admission with invasive blood pressure monitoring, and IV antihypertensive agents.  The goal is to reduce the MAP by around 25% within the first 24 hours because cerebral autoregulation may be accustomed to much higher blood pressures – reducing them to normotension immediately could be dangerous.  Hypertensive urgency on the other hand does not even always require hospital admission, and can be followed up as an outpatient with changes or adherence to oral medications.

-We talked about a young man (30’s) who had been found wandering the clinical areas and was referred to internal medicine for a presumed delirium or altered level of consciousness.  Because there were volitional changes in his level of consciousness and alertness, a psychiatric cause was much more likely.  The patient chose to leave AMA.  The learning point is that, despite it being a little bit ageist, the approach to a 30-year-old who is wandering, aggressive, or disoriented is usually different than that of an 80-year-old with the same syndrome.  A primary, new diagnosis of a psychiatric disease is almost impossible in the latter case.

-We talked about a young woman with disordered eating behavior who had substantial electrolyte disturbances.  In these situations, it is helpful to exclude diuretic abuse as a cause of weight loss and electrolyte abnormalities (an abnormally high urine chloride level >40mEq/L is usually sufficient).  The other teaching point was related to refeeding syndrome and intravenous volume expansion. Giving high volumes of isotonic fluid may exacerbate hypokalemia leading to arrhythmias.  Also, it is extremely challenging to correct hypokalemia without correcting hypomagnesemia first.  Finally, the patient had a very low phosphate which will predispose to weakness and even rhabdomyolysis.  The challenge is that with feeding these patients, their endogenous insulin secretion increases leading to potassium and phosphate shifting inside cells and exacerbating measured electrolyte abnormalities.  This must be done carefully, with monitoring, in a controlled environment.

-Finally, we talked about someone with severe dementia and an inability to feed herself.  We often associate malignant (cancerous) diagnoses with the need for palliation, but two overlooked clinical conditions are congestive heart failure and dementia.  Patients with severe dementia and inability to drink water or feed themselves have a six-month mortality worse than most cancers.  Likewise, patients with severe refractory heart failure and complications like cardiorenal syndrome are similar.  Our palliative care colleagues can be a tremendously helpful resource in this situation, as education to families about the futility of treatments like IV hydration and G-tubes is vital.

Image Credit: nursingcrib.com

Further Reading:

Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., ... & Levine, G. N. (2014). 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(24), e139-e228.

Marik, P. E. (2015). Hypertensive Crises. In Evidence-Based Critical Care (pp. 429-443). Springer International Publishing.

Mitchell, S. L. (2015). Advanced dementia. New England Journal of Medicine, 372(26), 2533-2540.