CCS Interactive Case 11 Flashcards
45 y/o M presents to the ED w/recent onset of N/V, blurry vision, HA. Long-standing hx of HTN, non-adherent to medications. BP 230/140. Denies chest pain, no focal neuro deficits. 25 pack-year smoking history.
First step?
Physical exam, which helps distinguish hypertensive urgency from emergency.
Most important parts - fundoscopy, CV, CNS exams, BP measurement in both upper extremities
Exam shows mild paipilledema
Examples of end-organ damage?
Retinal hemorrhages
Papilledema
Hypertensive encephalopathy (N/V, HA, confusion)
Stroke
Malignant nephrosclerosis, causing renal failure
Labs?
Stat head CT CXR BMP UA CBC
(Allows dx of stroke, pulmonary edema, renal impairment, hemolysis)
Most critical goal of hypertensive emergency?
Lowering BP
What must be done first?
Rule out stroke (sudden decrease in BP in setting of stroke can e catastrophic)
CT Head is negative. BP management?
Goal: lower DBP to 100 to 105 within 2-6 hours as long as the total drop in BP does not exceed more than 25% of the original value
More aggressive reduction is not recommended, as it may precipitate ischemic events such as stroke.
IV nitroprusside is the drug of choice (acts within seconds, very short half-life)
Monitor BP w/intra-arterial line
Transfer to ICU
Once 25% reduction is achieved, transfer to ward and switch to oral medications
Once controlled on oral medications, discharge hoe
Then lower DBP to 85-90 over a period of 2-3 months
Initial BP lowering management?
If no evidence of stroke, lower DBP to 100 to 105 mmHg over 2-6 hours. Do not drop by more than 25%
IV nitroprusside (first-line)
IV labetalol, nicardipine (alternatives)
Transfer to ICU
A-line for BP measurement
After 25% drop in BP achieved?
Ward
D/c A-line
Change to PO anti-hypertensive
Once BP under control
DC home
Lipid profile
Counseling (medication compliance, smoking cessation, exercise, limit alcohol intake, low salo diet)
Sequence?
Order: IV access, pulse oximetry, oxygen, cardiac monitor, BP monitor
Exam: focused (general, HEENT/neck, chest/lung, CV, abdominal, extremities/spine, neuro/psych)
Order: 12-lead EKG, head CT, CBC, BMP, UA, CXR-PA (all stat)
Clock: advance to obtain head CT. Note the increased BUN/Cr on BMP, mild proteinuria on UA, LVH on ECG, head CT is negative for stroke and hemorrhage
Order: nitroprusside, IV, continuous; A-line
Location: transfer to ICU
Order: NPO, complete bed rest, monitor urine output
Clock: advance 15 minutes to reevaluate the patient. BP has improved
Clock: advance to check BP every 30-60 minutes until under control and patient is symptom-free. Case ends
Final orders: lipid profile, routine counseling
Primary diagnosis: Hypertensive emergency
