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Evaluation of Hypertensive Emergency with Dr. Allison Cash

Definition: Hypertension (diastolic >120)  + end organ dysfunction

History Pearls

NeurologicalVisual changes, vomiting, seizures, focal motor or sensory deficits, confusion 
CardiacChest pain, abdominal or back pain, palpitations, syncope, dyspnea
RenalAnuria, hematuria, peripheral edema 

Exam Pearls

NeurologicalFocal neurological deficits, papilledema, retinal exudates or hemorrhages, AMS
CardiacUnequal pulses or BP, pulsatile abdominal mass, new murmurs, carotid bruits, rales
RenalPeripheral edema 

Manifestations of Damage

NeurologicalRetinopathy, encephalopathy, SAH, intracranial hemorrhage, acute ischemic stroke
CardiacAortic dissection, AMI or ACS, acute heart failure, pulmonary edema
RenalAcute renal failure 

Special Considerations

  • Pre-eclampsia, eclampsia, HELLP in pregnant or postpartum patients 
  • Sympathetic crisis in setting of sympathomimetic drug use, pheochromocytoma, MAOI-tyramine reaction, or withdrawal of short acting antihypertensives

References:

  1. Johnson, Nguyen, M.-L., & Patel, R. (2012). Hypertension Crisis in the Emergency Department. Cardiology Clinics, 30(4), 533–543. https://doi.org/10.1016/j.ccl.2012.07.011
  2. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill.
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Facial Blocks with Dr. Erica Westlake, PGY2

Why use facial blocks?

  • Indications include: laceration repair, acute migraine headaches, zoster outbreaks
  • Improved cosmetic healing with regional block compared to infiltrative anesthesia 
  • Block provides longer duration of anesthesia compared to infiltrative anesthesia 

How do you perform facial blocks?

  • The supraorbital, infraorbital and mental foramen should align with a line drawn vertically through the ipsilateral centered pupil 
  • Assess neurovascular status prior to anesthesia especially with trauma 
  • Massage area of anesthesia to assist with distribution 
  • Complications include: bleeding, hematoma, infection, incomplete anesthesia, vascular puncture, nerve injury, systemic local anesthetic toxicity, ocular injury
BlockAnatomyGuidance
Supraorbital 








Branch of frontal nerve which continues superiorly 


Branch of frontal nerve which continues medially 
-Supraorbital foramen is 2 cm laterally from nasal aspect of orbital rim-Block both the supraorbital and supratrochlear nerve by directing the needle first cephalad and then medially toward nasal spine
Supratrochlear
InfraorbitalBranch of maxillary nerve which continues medially and caudally -Infraorbital foramen is below the orbital rim at intersection of pupil and nasal alae
-Intraoral approach: inject into the buccal mucosa at canine and direct upward and outward
-Extraoral approach: laterally approach foramen until bone is hit, inject local anesthetic 
Mental Branch of mandibular (alveolar) nerve which continues medially -Mental foramen in line with premolar tooth
-Intraoral approach: retract lower lip and insert needle into mucosa of first premolar tooth, inject down and outward 
Extraoral approach: approach foramen laterally
 

References

Gibbs MA, Wu T. Local and Regional Anesthesia. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. 

Davies T, Karanovic S, Shergill B. Essential regional nerve blocks for the dermatologist: part 1. Clin Exp Dermatol. 2014 Oct;39(7):777-84. doi: 10.1111/ced.12427. PMID: 25214404. https://onlinelibrary.wiley.com/doi/pdf/10.1111/ced.12427 

Sola, C., Dadure, C. D., Choquet, O., & Capdevila, X. (2022, April 26). Nerve blocks of the face. NYSORA. https://www.nysora.com/techniques/head-and-neck-blocks/nerve-blocks-face/