288 Emergency Medicine
focal neurologic deficits, or coma. Hypertensive emergency is a medical
emergency. The goal of therapy is to stop and reverse the progression of
end-organ dysfunction while maintaining organ perfusion and avoiding
complications. Reduction in BP should be done rapidly but carefully. It is
important to avoid dropping the pressure too low as this may lead to cere-
bral ischemia. The immediate goal is to reduce the mean arterial BP by 20%
to 30% of pretreatment levels over the first hour of therapy. This can be
accomplished by labetalol, a β 1 -,β 2 -, and α 1 -receptor blocker. Another
useful medication is nitroprusside, which is a better choice if the patient’s
BP is being monitored through an intra-arterial line. Nitroprusside can
cause a reflex tachycardia.
(a)Propofol is an excellent sedating agent that has a rapid onset of
action and metabolizes quickly. It is also known to cause hypotension and
apnea as side affects. However, it should not be used as an antihypertensive
because of its unpredictable properties. (b)Mannitol is an osmotic agent that
is used to lower ICP in patients with impending or actual brain herniation. It
is not appropriate as an antihypertensive agent. (c)Diuretics are not useful to
acutely lower BP, but may be started as a maintenance antihypertensive.
(d)Loweringthe BP to 140/80 mm Hg can cause cerebral ischemia. The mean
arterial pressure should only be lowered by 20% to 30% in the first hour.
- The answer is b.(Rosen, pp 1527-1538.)The CSF analysis in
bacterial meningitistypically shows an elevated WBC countwith pre-
dominantpolymorphonuclear leukocytes. Protein is elevated and glu-
cose is low. A Gram stain may show bacteria. The most specific marker for
the diagnosis is a positive culture. Tests that evaluate the presence of anti-
gen in the CSF (eg, latex agglutination studies) are particularly useful in the
diagnosis of partially treated bacterial meningitis.
(a)TB meningitis typically presents with less than 1000 WBC/μL with
monocytic predominance. Symptoms are generally insidious in nature,
Test Normal Bacterial Viral Fungal TB
Protein < 50 > 200 < 200 > 200 > 200
Glucose > 40 < 40 > 40 < 40 < 40
WBCs < 5 > 1000 < 1000 < 500 < 1000
Cell type Monos > 50% Polys Monos Monos Monos
Gram stain Neg Pos Neg Neg Pos (AFB)