Chapter 84 - Hypertension Flashcards
Define the three classes of hypertension relevant to ER?
1) Hypertensive emergency: acute target organ dysfunction, manifesting with newly developed clinical sequelae or consequential diagnostic test abnormalities
2) poorly controlled chronic HTN: known HTN patient with asymptomatic elevated BP without end organ dysfunction
be aware of drugs that can increase BP; NSAIDS/new steroids/devongestants/ appetite suppressants/ OTC stimulants/ OCPs/ TCAs
3) Elevated BP without prior hx of HTN -cannot really diagnose it in the ER (white coat?) - outpt followup
List 10 possible etiologies for hypertension
1) primary HTN
90% of patients
2) secondary hypertension
a) Endocrine: Cushing’s, hyperaldosteronism, pheochromocytoma, thyroid disease, parathyroid disease
b) pulmonary: OSA
c) renal: nephritic syndrome, nephrotic syndrome, polycystic kidney disease, renal artery stenosis, diabetic nephropathy
d) toxic: chronic alcohol use, sympathomimetic use
e) Vascular: atherosclerosis, coarctation of the aorta (CT-angiography
How does hypertensive encephalopathy occur?
A true emergency:
SSx: severe headaches, vomitting, Altered LOC, seizures, coma, blurred vision, neurological deficits in multiple nerve distributions (due to diffuse cerebral dysfunction)
PE; CT head normal, markedly elevated BP, papilledema
Net result: worry about exploding head due to Na shift too fast - edema
What are some of the ER diagnostics ordered in the hypertensive patient
CBC (look for MAHA) Metabolic pannel - with Cr and eGFR Urine- for urine ACR and proteinuria CXR - dissection etc ECG \+/- troponnin CT fundoscopy ( may be normal in up to 30% of people with HTN emergency)
List 5 intravenous antihypertensives and mechanism of action
1) Labetolol: mixed alpha and beta blockers (adrenergic inhibitor)
2) Esmolol, metoprolol: beta blocker (adrenergic inhibitor)
3) enalaprilat: ACEi
4) hydralazine - direct acting vasodilator
5) diltiazem, verapamil: non-dihydropyridine CCB
6) clevidipine, nicardipine: dihydropyridine CCB
7)furosemide loop diuretics
8_ nitroglycerin, sodium nitrorusside: nitric oxide donor
What is the ER managemet of poorly controlled hypertension
❏ If they have a GP or internist = nothing to be done in ED
❏ If they don’t have follow-up, Rosen’s suggest initiating antihypertensive agent and
arranging follow-up is possible
What are the management target/indications for treatment of:
57 year old male with ICH and no signs of increased ICP:
1) sBP target- 140-179
According to ATACH II (SEE SGEM here) no benefit of aggressive
management, so we will stick with SBP goal of 140 -179
2) Labetolol/esmolol/nicardipine are good choices.
3)nitrrous oxide donors (i..e nitroglycerin, nitroprusside) should be avoided as they can increase ICP
What are the management target/indications for treatment of:
58 year old female with acute ischemic stroke?
1) 185/110 if thrombolysis planned
2) 220/120 if no thrombolysis
3) decrease BP by 15% in 24 hours
What are the management target/indications for treatment of:
39 year old female with SAH in the ED:
1) ensure appropriate pain control and sedation before adding hypertensive
2) discontinue reveres all anticoagulation:
a) coumadin —– give prothrombin complex conc or FFP + Vitamin K
b)Aspirin —- DDAVP
c) plavix —- platetel (controversial)
d) dabigitran (Pradaxa) —– Idarucizumab (praxbind) 5 grams IV
3) AVOID HYPOTENSION: give IV fluids if needed
target sBP <160
4) nimodipine (CCB) - for HTN; prevent vasospasm so best agent in SAH ptient.
-60mg Q4H PO or NGT within 96 hr of SSx onset
5) Mg sulfate: controversial:
6) seizure prophylaxis: 3 day course (controversial)
7) glucocorticoid therapy (controversial)
8) Glycemic control (constroversial) - sliding scale while awaitng ICU
9) Keep head of the bed elevated
What are the management target/indications for treatment of:
22 year old female with eclampsia:
1) delivery of baby is definite management (can happen post delivery_
2) sBP <160 or until they stop seizing
3) Mg sulfate - start with 6mg IV , may need up to 20
4) _+/- hydralazine/labetolol
What are the management target/indications for treatment of:
66 year old female with ACS:
1) primary goal is reperfusion
2) titrate sBP to symptom resolution but avoid droping beyond 120/80
3) NO donors (nitroglycerin) are first line but don’t use with concurrent PDE5 inhibitors (i.e. viagra)
4) avoid beta blockers in early treatment
What are the management target/indications for treatment of:
57 year old male with aortic dissection:
1) THINK LOW AND SLOW
2) first pain control - to counter sympathetic contributed to elevated HR
i. e. fentanyl 25-50 mcg boluses
3) HR control to goal of 60bpm
i. e. esmolol or labetaolol
4) sBP goal of 110
i. .e nitroprusside then tritrate
What are the management target/indications for treatment of:
62 year old female with ICH decreased GCS and shift on CT scan
standard herniation syndrome treatment:
1) HOB elevated
2) do not occlude vascular structures - collars, neck compression, head midline)
3) SBP: 140-160
4) MAP >80 or CPP >55 if measured ICP \
5) tx with mannitol or hypertonic saline
6) hyperventilation to PaCO2 30-35
7) NeuroSx stat
8) Reverse anti-coag
