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MISCONCEPTIONS ABOUT HYPERTENSION

 Dr Himanshu Gul Mirani

Emergency Physician and Centre Head

UCC, Kalkaji

1.       Hypertension can’t be asymptomatic

Hypertension is a silent killer. It’s very much possible to have high BP and yet be asymptomatic. Symptoms like headache/ nausea/ vomiting/ chest pain/ shortness of breath –may not be present at the very outset of disease.  

It’s not a rule that BP is high only when you can feel it!

Usually such patients present to ER upon decompensating into “Hypertensive Crisis”.

2.       Anti-hypertensive medicines need to be discontinued once normal values are recorded

Your normal values may well be because of the anti-hypertensive medicines itself. So don’t discontinue them without a proper physician consult.

Sudden discontinuation of these medicines without medical supervision can predispose the patient to “rebound hypertension” and precipitate “Hypertensive Crisis”.

3.       It’s OK to miss my doses of medicines – anyways I take them every day, so some drug holiday is allowed

Non drug compliance itself is thought to cause about 89000 pre mature deaths in USA per annum. These deaths are simply preventable by practicing drug regime adherence.

So don’t skip your doses. It would only undo the good.

4.       It’s been quite some time since I saw my doctor & I am continuing with my prescription which is ages old

It’s very much advisable to have a diligent follow up with your GP, although you may be having a good control of BP with your current medicines. Anti-hypertensive medicines have their own side-effects which need to be monitored, eg patients on ACE Inhibitors need Kidney Function Tests regularly at the commencement of therapy and continuation of therapy. Diuretics predispose a person to dyselctrolytemia. Maybe the cough for which you are gulping OTC cough syrups is a side effect of ACE inhibitor drug.

So do keep visiting your GP as advised by him/her.

Also maybe after implementing positive therapeutic lifestyle interventions you may need drug dose reduction!

5.       I left exercising as it increases BP

Exercising to the best of one’s capability and capacity is advisable to even heart failure patients. It has been established that regular permissible exercise and weight management can only have positive impact on one’s health.

In fact for every 10kg weight loss SBP may fall between 5-20 mmHg and if one does regular exercise for about 30-45 mins – on most days of a week, preferable 5 out of 7; this itself can bring a fall in SBP of 4-9 mmHg. Sedentary life style is one of the leading risk factor predisposing to hypertension.

6.       High BP affects only oldies

The disease has epidemically plagued the Gen Y and Gen Z and is no longer limited to the Baby Boomers. There is enough evidence to testify that the young are fast getting engulfed by hypertension.

High stress levels, lack of physical activity, tobacco and alcohol addiction, excess salts in packaged and processed foods, fast foods – all contribute immensely to increase the disease load.

7.       Medicines are ineffective in old patients and they can’t hit their “goal BP”

With the multiple drugs in the armamentarium of your physician – the drugs are very much capable to help you attain your target level of BP. These drugs act by varied mechanisms to help an individual attain the desired control of BP.

Target BP is determined based on one’s other co-morbid conditions - more the co-morbidities like diabetes and chronic kidney disease – the more stringent the control of BP.

8.       Medicines are the only way to control BP

Non pharmacologic methods to control BP have a very well established role in today’s BP management methodology. They have variable effects depending upon individuals. The following are the suggested measures:

·         Decrease sodium (salt) intake

·         Regular exercise on most days of a week

·         Weight reduction

·         Moderation of alcohol consumption

·         Quit smoking

·         Follow DASH diet

For any feedback/ suggestions/ query regarding this article; contact the author on himanshu.mirani@urgentcare.co.in

Call us Toll Free at 1800 208 1188

Or SMS UCC to 52424 to know more about UCC Hospitals and Hospitals in Delhi.

Common Household poisonings in children- A Preventable Condition

Dr Bharat Choudhary

Consultant, Pediatric Emergency Medicine, UCC

Parents often think that home is safest place for children. But there are so many things in the house for daily use which could be dangerous to children.  Inherent tendency of infants and toddlers to direct the things from hand to mouth increase the possibility of the same. Over a year in USA, poison center receive 3.6 million calls of such incident, means every eight second one call, so this is quite clear that it is not uncommon. For parent information, describing about few such common household poisons, their effects and methods of prevention.

Common Household poisons-

With increasing number of different chemicals used in home, list of possible household poisons are also increasing. As said by Paracelsus (Father of toxicology)  that – ‘’All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.’’ There is long list of chemicals used on day today basis which can be dangerous for children if taken in significant amount. For example-Pharmaceuticals (pain killers, antiepiletics, antidiabetics, vitamins, iron preparations), hydrocarbons (kerosene, petrol, thinner), cleansers, pesticides, rat killers, cosmetics , plants and much more.

The great majority of such poisonings have no or limited clinical effects. Many of such children require only observation but a few poisons can kill after ingestion of very small amounts. Unintentional poisoning can be much more serious following ingestion of kerosene, caustic agents, herbal remedies, insecticides or herbicides. Management of symptomatic patients involves supportive care, if available the administration of antidotes, and the removal of the offending drug from the body.

Common poisonings, their effect and initial management

S.NO	Poison	System affected	Line of Treatment
1	Pain killer ( paracetamol)	liver and biliary system – liver failure	Gastric lavage, N acetyl cystiene
2	Kerosene	Chemical pneumonitis with acute respiratory distress syndrome	Observation , chest x-ray and monitoring
3	After shave, perfumes, alcohols	CNS and respiratory depression , hypoglycemia	Observation, glucose monitoring, IVF
4	Bleach	Esophageal injury , acidosis	IVF, observation
5	Detergents	Esophageal injuries, chemical pneumonitis	Observation
6	Nail paint remover	Mucosal injuries, respiratory depression , CNS depression	observation
7	Rat Killer	Coagulation system	Vit K , observation, coagulation study
8	Camphor	CNS irritant , seizures	Gastric lavage, antiepileptics, observation
9	Pesticides (Organophosphorous)	Vomiting, diarrhea, seizures	Gastric Lavage, PAM, hospital admission
10	Iron Preparations	Hepatic Dysfunction, renal dysfunction	Gastric lavage, Observation, Deferoximine

Who is at most risk?

Usually toddlers 1-3 years are more prone for such  accidents because they are they are extremely curious and active they tend to put everything in their mouths  their taste buds and sense of smell aren’t developed to warn them that a substance is dangerous because it tastes or smells awful.

How does it happen?

It happens mostly when this chemical is in use and children started playing around them unattended. When they are not properly placed after their use and also when they are not disposed well.

What to do?

If you suspect your child has eaten something which is not to be eaten then

-          Don’t wait for your child to be more sick

-          Don’t panic, remain calm.

-          Nearest Urgent Care Hospital  -  1800–208-1188 ( Toll Free)

-          Call National Poisoning center (AIIMS Poison cell)  26593677, 26589391, 26583282

 Trained professionals will answer your queries, and help to determine the seriousness of a poisoning, and give specific advice on how to deal with the incident. While talking to these centers please be ready to answer common questions like -

• The age and weight of the child, since toxicity usually is based on these factors
• When the child was exposed
• How much the child ate, drank, or spilled
• The child’s general health status
• Whether the child has any signs or symptoms
• What actions have already been taken
• Keep the container near you and read out the content ( either exact brand name, or active ingredient)
• This information is very vital in assisting you and providing proper medical advice.

Don’t DO’s for parents

• If any child accidently taken some household poison and swallowed, the most common mistake parent does is putting fingers in the mouth and try to extract it or make the child vomit. This is very dangerous practice; it does more harm than benefit. This will may lead to pushing the solid object more deeper may be in respiratory tract or if vomiting happens that may increase the chance of aspiration and further complications ,and  if fingers goes more deeper it can injure  oral mucosa also. So attempt to remove the poison should only be done if it is solid and not deep into oral cavity and can be easily removed by fingers.
• Do not give anything by mouth unless advised

How to prevent such Mishappening?

Prevention of such incident can be done by proper storage, use and disposal of these harmful chemicals. Even after taking all the precaution such incidents do happen, so parents should know basic first aid and how to access the poison center. (write to info@urgentcare.co.in if you want to learn first aid )

Following are the basic steps to avoid such incident-

Store toxic products out of reach of children

Medications, Pesticides, house cleansers and other toxic substances should be kept in     shelves at least six feet and above.

Keep products in their original containers

Do not keep medications, chemicals, house cleansers, pesticides in food or beverage container or vice versa. This commonly happen at home, that after medicine or chemical got over they use empty container  for storing other substances or liquids which other person or children does not know and leads to unintentional poisoning.

Keep labels on containers

Label all the containers with name of the product they contain presently and remove the old labels if you are using the container for storing other substance then it was containing originally.

Never combine products

Do not mix household cleansers together because certain combinations can be explosive or can produce toxic fumes.

• Never give medication to children meant for adult.
• Be aware of all kind of medication used in home
• Never refer medication as candy or taste like candy to children
• Always put medications away immediately after use, out of reach and sight, preferably locked away.
• Ensure the cap’s child resistant closure is working correctly after each use.
• Use wax block rat baits, preferably those enclosed in plastic bait stations.
• Don’t leave brushes to soak in mineral turpentine. Clean them immediately or keep them out of sight and reach of children until you can clean them properly.
• Educate your children about the potential harm of common household substances

So to summarize, unintentional household poisonings are common but preventable and if taken appropriate steps timely serious and long term complications can avoided.

For more blogs and write ups like this visit www.urgentcare.co.in

Pacemaker Malfunctions

DR HIMANSHU GUL MIRANI

EMERGENCY PHYSICIAN

With increasing number of patients walking home with a pacemaker for their cardiac care, it has become quite a common scenario to encounter a bizarre ECG strip with a symptomatic patient and maybe a malfunctioning pacemaker! It’s extremely vital to sense a pacemaker malfunction so as to coordinate with the cardiology team and the manufacturer for further evaluation and management.

In this article I have tried to highlight some very common pacemaker malfunction phenomena and the possible patient presentation to the ER along with a simplified scheme to approach such patients and concluded it with some handy tips for the patients on pacemakers.

Common errors and their causes:-

1. Self tampering

Called as Twiddler’s Syndrome, it’s due to fiddling of the device by the patient themselves. These patients need more counseling to understand the implications of such acts.

2. Runaway

Rare, but seen in case of low battery nearing replacement, especially in patients who have irregular follow up. Low battery causes low amplitude pulses and inadequate stimulus. There is non-physiological erratic heart stimulation with rate up to 2000 bpm!

It needs deactivation of the pacemaker using a magnetic field but definitive treatment is replacement of the battery.

3. Endless loop tachycardia

It s caused due to retrograde conduction of ventricular impulse into the atria leading to a vicious endless loop producing pacemaker mediated tachycardia. This high heart rate may induce ischemic changes in the heart muscle. Magnetic inhibition is warranted to terminate the tachycardia.

4. Sensing issues

Under-sensing may occur when the pacemaker would not detect the inherent cardiac activity and hence fire asynchronously. It may occur due to lead dislodgement or insulation breach or programming error.

Over-sensing would occur when some non-cardiac activity is detected as cardiac electrical impulses leading to malfunction. Over-sensing stimuli may be from muscle activity of diaphragm or pectoralis or from external sources like MRI.

5. Failure to capture

When the pacemaker stimuli are not followed by atrial or ventricular depolarization, it’s referred to as failure of capture by the pacemaker. It can be due to numerous causes like circuit failure, dyselectrolytemia, infarction or fibrosis under the pacemaker tip etc.

Such patients need temporary pacing till the definitive management is done by correcting the device setting or treating the pathology like electrolyte imbalances.

6. Pacemaker syndrome

Seen in ventricular pacing, where due to asynchrony, atria may contract when the ventricles are in systole from pacemaker impulse. Hence the atria contract against closed AV valves, leading to worsening of patient symptoms rather than improvement.

Such patients need Dual Chamber Pacemakers rather than just ventricular stimulation.

Patient presentation:-

·         Worsening of symptoms.

·         Chest pain.

·         Engorged neck veins.

·         Shortness of breath.

·         Palpitations.

·         Manipulation marks over the site of pacemaker insertion indicating tampering.

·         Dizzy feeling.

·         Lightheadedness.

·         Racy pulse.

How an ER physician should proceed:-

·         Take the vitals.

·         Give supplemental oxygen.

·         Give a fluid challenge for low BP, may need inotropic support.

·         Get a 12 lead ECG.

·         Send blood samples for electrolytes, ABG – correct any imbalances.

·         Send cardiac enzymes to detect any fresh insult to the heart.

·         Send drug levels of medicines which the patient is on and which can alter the conduction (eg – flecainide).

·         External pacing may be needed.

·         Do a chest x-ray as a lot of clues like lead dislodgement/ lead fracture etc can be noted on the x-ray. Ask for an over penetrated film. A CT-Scan is more conclusive.

·         Ask for regularity of follow up with the cardiologist and the last check date, note the model type and pacemaker code and get in touch with the cardiologist and electro-physiologist for a possible recalibration or battery change.

·         Magnet application – it helps to convert the pacemaker to asynchronous mode and thus detect low battery or failure to capture.

·         Always keep cardiologist, CTVS surgeon and electro-physiologist in the decision making loop.

Tips for patients:-

·         In case patients sense any of the symptoms as enlisted above – they must seek medical help immediately at the nearest centre.

·         Be regular in follow up – it would ensure proper care of the pacemaker and it’s various components like leads, generator, battery etc. Malfunction of any component can lead to device failure.

·         Always carry with you a laminated card mentioning the pacemaker type, model, manufacturer’s name and contact, treating doctor’s name and contact number, list of current medications, any known allergies & names and contacts of people to be informed case of emergency.

·         Don’t manipulate/ fiddle with the pacemaker.

·         In case external hindrance to pacemaker function is expected as in case of MRI – inform the doctor/ attendant about it.

·         The manufactures give a list of possible conditions which interfere with the pacemaker – avoid these conditions always.

For more blogs and write ups like this visit www.urgentcare.co.in

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