Abnormal Vitals

Bradycardia

Rapid Review

  • Differentials
    • Medication/intoxication
      • Beta-blocker/Calcium channel blocker
      • Central alpha-2 agonists
      • Cholinergic agents
      • Antiarrhythmics
      • Benzodiazepines/alcohol/opiates
    • Metabolic
      • Hyperkalemia
      • Hypermagnesemia
      • Hypothyroidism
      • Hypothermia
      • Hypoglycemia
      • Severe hypoxia
    • Cardiac
      • Myocardial infarction
      • Sick sinus syndrome
    • Environmental
      • Hypothermia
  • History
    • Recent excessive ingestion of medications or substances
      • Consider toxicologic etiologies
    • Hx of renal disease or endocrine related disease
      • Consider electrolyte abnormalities
    • Hx of cardiac disease
      • Consider MI
  • Physical Exam
    • Altered mental status
      • Suggests hemodynamic instability; warrants rapid response
    • Pinpoint pupils
      • Suggests toxic ingestions
    • Signs of pulmonary congestion (rales, B-lines)
      • Suggests cardiac failure
    • Cushing’s triad (Hypertension, bradycardia, irregular respirations)
      • Suggests elevated intracranial pressure
  • Work-Up
    • EKG
      • Determine type of bradycardia
    • Labs
      • CBC, BMP, Troponin, TSH/FT4
    • Imaging
      • Chest X-ray
      • Head CT (if in setting of head injury)

Pearls

  • The severity of the patient’s bradycardia does not always necessarily correlate with the number on the monitor. Treat the patient, not the number!
  • Always consider metabolic etiologies (eg. hypothyroidism, hypothermia, hypoglycemia, hyperkalemia). These patients will often not respond to standard therapy (pacing, atropine, etc.)

Deep Dive

Video Credit: AETCM Emergency Medicine

Tachycardia

Rapid Review

  • Differentials
    • Narrow Complex Tachycardia
      • Regular
        • Sinus tachycardia
        • Atrial tachycardia
        • AVNRT
      • Irregular
        • Atrial fibrillation
        • Multifocal atrial tachycardia
        • Atrial flutter
    • Wide Complex Tachycardia
      • Ventricular tachycardia
      • Antidromic AVRT 
      • LBBB w/ aberrancy
      • Accelerated idioventricular rhythm
    • Non-cardiac causes
      • Fever
      • Pericarditis
      • MI
      • PE
      • Asthma/COPD
      • Anemia
      • Anxiety
      • Dehydration
      • Electrolyte imbalance
      • Pain
      • Trauma
      • Sympathomimetics
  • History
    • Hx of arrhythmias
      • Consider atrial fibrillation/flutter, PSVT, etc.
    • OCP’s, prolonged immobilization, recent trauma/surgery
      • Consider PE
    • Substance abuse
      • Consider cocaine use
    • Hx of mental illness
      • Consider anxiety/depression as diagnosis of exclusion
    • Fever/chills
      • Consider sepsis
  • Physical Exam
    • Hypotension/AMS
      • Hemodynamic instability; requires rapid intervention
    • Dry mucous membranes
      • Suggests dehydration
    • Abnormal lung sounds (ex. rales)
      • Suggests pulmonary edema; L-sided heart failure
    • Chest pain when leaning back
      • Suggests pericarditis
  • Work-Up
    • EKG
      • Determine type of tachycardia
    • Labs
      • CBC, BMP, Troponin, TSH/FT4, Urine drug screen
    • Imaging
      • Chest X-Ray

Pearls

  • If you see what appears to be a ventricular tachycardia, but it appears to be “too wide or too slow”, think hyperkalemia!
  • Always consider infection in patients presenting with tachycardia. Sepsis can cause both sinus tachycardia and supraventricular tachycardia.
Video Credit: Anna Pickens

Hypotension

Rapid Review

  • Differentials
    • Distributive
      • Sepsis
      • Anaphylaxis
      • Neurogenic
      • Addisonian Crisis
    • Cardiogenic
      • Arrhythmia
      • Myocardial infarction
      • Congestive Heart Failure
    • Obstructive
      • Cardiac tamponade
      • Tension Pneumothorax
      • Pulmonary Embolism
    • Hypovolemic
      • Hemorrhage
      • Dehydration
    • Neurogenic
      • Spinal cord injury
  • History
    • Chest pain or dyspnea on exertion
      • Consider cardiogenic shock 
    • Recent viral/bacterial illness
      • Consider septic shock
    • Allergies
      • Consider anaphylaxis
    • Recent injury
      • Consider hemorrhagic or neurogenic shock
    • Hx of endocrine conditions
      • Consider adrenal insufficiency
  • Physical Exam
    • Signs of trauma
      • Suggests hemorrhagic shock
    • Beck’s triad (muffled heart tones, JVD, hypotension)
      • Suggests cardiac tamponade
    • Urticaria or angioedema
      • Suggests anaphylactic shock
    • Diminished breath sounds unilaterally, JVD, tracheal deviation
      • Suggests tension pneumothorax
    • Dry mucous membranes
      • Suggests dehydration
  • Work-Up
    • EKG
    • Labs
      • CBC, CMP, hCG, blood cultures, UA, ABG
      • lactate, troponin, type and cross
    • Imaging
      • Ultrasound (RUSH exam)
      • CXR
      • CT (Head, chest, abdomen)

Pearls

  • Point of care ultrasound can rapidly several different etiologies of hypotension (cardiac tamponade, tension pneumothorax, intraabdominal bleeding, etc.). Keep it handy!
  • Hypotensive patientsnotresponding to fluids or vasopressors should be considered for adrenal insufficiency, hypothyroidism, acidosis, or occult bleeding.
Video Credit: Strong Medicine

Hypertension

Rapid Review

  • Differentials
    • Neurological
      • Hypertensive encephalopathy
      • Ischemic/hemorrhagic stroke
    • Cardiac
      • CHF
      • ACS
      • Aortic dissection
    • Pulmonary
      • Pulmonary edema
    • Renal
      • Renal artery stenosis
      • Nephritic/Nephrotic syndrome
    • Endocrine
      • Hyperthyroidism
      • Hyperaldosteronism
      • Cushing’s syndrome
    • Toxicological
      • Sympathomimetic ingestion (cocaine)
    • Obstetric
      • Pre-eclampsia/eclampsia
  • History
    • History of heart disease
      • Consider ACS/CHF
    • History of endocrine disease
      • Consider hyperthyroidism or hyperaldosteronism
    • Using blood pressure medications
      • Consider lack of adherence
    • Pregnant
      • Consider (pre)-eclampsia
  • Physical Exam
    • Presence of end-organ damage (AMS, AKI, pulmonary edema, MI)
      • Indicates hypertensive emergency; warrants rapid intervention
    • Abnormal lung sounds (rales, wheezing)
      • Suggests L-sided heart failure
    • JVD, peripheral edema
      • Suggest R-sided heart failure
    • Neurological deficits (facial droop, hemiplegia, etc.)
      • Suggests CVA
  • Work-Up
    • EKG
    • Labs
      • CBC, BMP, troponin, BNP, UA
    • Imaging
      • CXR
      • Head CT

Pearls

  • The clinical presentation matters more than the number. Evaluate hypertensive patients based on their symptoms and presence of end-organ damage as opposed to the number representing their blood pressure.
  •  Hypertension in pregnancy should be taken seriously. Patients with hypertension that occurs > 20 weeks gestation should be evaluated for preeclampsia.
Video Credit: Anna Pickens

Hypothermia

Rapid Review

  • Differentials
    • Decreased heat production
      • Hypothyroidism
      • Adrenal insufficiency
      • Hypopituitarism
      • Nutritional deficiencies
    • Increased heat loss
      • Burns (loss of skin insulation)
      • Cold water immersion
      • Cold/freezing weather
      • Trauma
      • Sepsis
  • History
    • Prolonged cold weather exposure
      • May have frostbitten extremities
    • Alcohol/drug use
      • May induce vasodilation, precipitating heat loss
    • History of endocrine disorders
      • Consider hypothyroidism or adrenal insufficiency
    • Homeless
      • Consult social work/case management prior to discharge
  • Physical Exam
    • Mild hypothermia (90 – 95 degrees F)
      • Tachycardia, shivering, impaired cognition
    • Moderate hypothermia (82.4 – 90 degrees F)
      • Bradycardia, hypertension, stupor, sluggish reflexes
    • Severe hypothermia (< 82.4 degrees F)
      • Unresponsive, ventricular dysrhythmia, marked hypotension
  • Work-up
    • EKG
      • Identify ventricular arrhythmias
      • May see Osborn waves at temperatures < 89 degrees F
    • Labs
      • CBC, BMP, fingerstick glucose, toxicology screen
    • Imaging
      • CXR
        • Pneumonia is a common complication

Pearls

  • Esophageal probes are the most reliable modality of measuring core temperature. Rectal and urinary cathter probes lag behind core temperature by approximately 1 hours. 
  • Always consider metabolic causes of hypothermia (hypothyroidism, hypopituitarism, hypoadrenalism) in patients who do not have a clear cold-weather environmental exposure.
Video Credit: Larry Mellick

Fever

Rapid Review

  • Differentials
    • Infectious
      • Meningitis
      • Pneumonia
      • UTI
      • Skin/Soft-tissue infection
      • Osteomyelitis
      • Influenza
      • Gastroenteritis
      • Cholecystitis
      • Pancreatitis
    • Toxicological
      • Sympathomimetics
      • Anticholinergics
      • Alcohol withdrawal
      • Serotonin syndrome
      • Neuroleptic Malignant Syndrome
    • Endocrine
      • Thyroid storm
      • Pheochromocytoma
      • Diabetic Ketoacidosis
    • Neurologic
      • Status epilepticus
      • Stroke
    • Environmental
      • Heat exhaustion
      • Heat Stroke
  • History
    • Respiratory symptoms
      • Consider influenza, COVID-19, pneumonia
    • GI symptoms
      • Consider gastroenteritis
    • History of thyroid disease or diabetes
      • Consider endocrine etiology
    • Recent physical activity or environmental exposure
      • Consider heat injury
    • Recent ingestions of new or excessive medications
      • Consider sympathomimetics, serotonin syndrome, etc.
    • Urinary symptoms
      • Consider UTI or pyelonephritis
  • Physical Exam
    • Abnormal lung exam
      • Suggests pulmonary infections
    • Tender abdomen
      • Consider pancreatitis, appendicitis, cholecystitis, etc.
    • (+) Kernig’s or (+)Brudzinski sign
      • Suggests meningitis
    • Exophthalmos
      • Suggests hyperthyroidism
  • Work-Up
    • Labs
      • CBC, CMP, Lactate, Urinalysis, Blood cultures, CK
    • Imaging
      • Chest X-Ray
      • RUQ Ultrasound

Pearls

  • No child should have a fever within the first month of life! Approximately 5-15% of febrile neonates will have a serious bacterial infection. These patients should be treated empiricially while awaiting blood/urine/CSF cultures. 
  • Beware of hyperpyrexia, which is considered any fever > 106.7 degrees F. These patients will not respond to antipyretic agents. Consider heat stroke, neuroleptic malignant syndrome, thyroid storm, or intracranial hemorrage as the etiology.
Video Credit: CritIC