223 ) A 38 year old obese African American man presented to the emergency department with headache, blurred vision and weakness. His past medical history was unremarkable. He smoked about 1 pack per day for 20 years. On examination, this patient’s blood pressure was 210/140 mmHg, heart rate 98/min, RR 20/min and temperature 98.6 F. He is alert, awake and oriented. Physical examination is unremarkable. There are neurological deficits. Laboratory investigations showed Hemoglobin 8.2 g/dl, White cell count 10k/µl, Platelets 97000/µl, Sodium 140meq/L, Potassium 4.0meq/L, Bicarbonate 24meq/L, BUN 34 and Creatinine 3.2mg% . Further investigations included a Lactic dehydrogenase which was elevated at 900U/L and a reticulocyte count of 7.0% . A periphreral smear is shown below :
The most appropriate next step in managing this patient:
A) Fresh frozen plasma
B) Intravenous Labetalol
C) Plasmapheresis
D) Intravenous Nitroprusside
E) Hemodialysis
I would go with “C”
B
I opt for “B”, we need to address this hypertensive crisis ASAP first.
This patient seems to have end organ damage from hypertensive emergency.. is it D?
Correct answer is:D
D is the correct answer because its a short acting with fast response. For BP>200/120 IV Nitroprusside is recommended with ICU monitoring to observe for Cyanide toxicity then switch to Oral antihypertensive meds. Labetelol can be used as well.
Correct answer is C. Plasmapheresis is a treatment for Acute sickle cell crisis clinically present with Stroke and Acute chest syndrome with pulmonary infiltrates on CXR. The purpose of plasmaphereses, or therapeutic cytopheresis is to decrease the number of sickle cells.
D. coz my lecturer said so.
Hey everyone, I am so wrong with my first answer!
The cell in the middle of the slide is a fragmented Erys due to intravascular hemolysis. The pt has malignant HTN with microangiopathic hemolytic anemia and thrombocythopenia. The answer is still C. Plasmapheresis.
i think it is c
he has acute intravascular hemolysis and schiotocytes are clear in the film with other signs including renal failure.
he also needs corticosteroids
Ans:D , I think it is imp to control hypertension and make certain that there is minimal kidney damage, once the BP is controlled further therapy and management can be discussed.
iv labetalol
Plasmapheresis….
i think its nitroprusside.as it causes vasodilatation.may be beter for decreased renal function
The patient mentioned in the question has evidence of micro-angiopathic hemolysis as evidenced by schistocytes (fragmented RBC) on peripheral smear, increased LDH and reticulocytosis. Malignant hypertension is one of the very important causes of micro-angiopathic hemolysis ( other important causes are TTP, HUS, DIC, HELLP in pregnancy). This patient presents with extremely elevated blood pressure and target organ dysfunction (renal failure) secondary to malignant hypertension . This should be considered as Hypertensive emergency and patient must be started on antihypertensive therapy. Labetalol is the drug of choice here because sodium nitroprusside is contraindicated in renal failure.
Though an extremely important differential diagnosis here includes TTP, the presence of such extremely elevated blood pressure indicates that Malignant hypertension is the etiology of Micro-angiopathic hemolysis ( MAHA) here rather than TTP. Hence, malignant HTN must be immediately treated and patient should be closely monitored for response in hemolysis. With adequate control of blood pressure, MAHA in malignant HTN responds promptly.
I’d go with C
Labetalol is a combined alpha and beta blocker that will treat both tachycardia and hypertension
while Nitroprusside would only treat the hypertension with a relfex tachycardia !!
MICROANGIOPATHIC HEMOLYTIC WITH SHISTOCYTES, THROMBOCYOTPEINA AND RENAL IMPAIRMENT
HUS
sickle crisis……
its clinical picture of end organ damage due to hypertension causing hypertensive encephalopathy and microangiopathic hemolytic anemia..so the patient needs to be treated with intravenous labetalol as nitroprusside cant b given in renal failure
Hypertensive crisis , pt. needs IV Na nitroprusside . Answer is D
iv labetelol
i believe labetalol…b
D …. she has malignant HTN …. Correct it with nitruprusside 1st …. then treat anemic crises with plsmapheresis
B. IV labetolol…