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Gen Med: Emergency Med > HTN Emergencies > Flashcards

HTN Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

HTN urgency

A

sxs of HTN without acute end organ damage

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2
Q

HTN emergency

A 
1. HTN with ACute end organ damage
A. Papilledema: Elevated ICP
B. AV nicking
C. Cotton wool stops
D. Acute stroke: need to determine which came first: stroke or HTN
E. MI
F. Heart failure/pulmonary edema
G arrhythmias
H. Aortic dissection
I. Acute hematuria
J. Acute Renal failure
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3
Q

Elevated BP

A

over pt’s normal, no evidence of end organ damage. Pt does not need immediate treatment in the ED, but does require proper follow up

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4
Q

What method medications will be used for HTN emergencies?

A

IV

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5
Q

How much do you want to reduce the bp in a HTN emergency?

A

25% over first 1-2 hrs

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6
Q

What method medications should be used for HTN urgency?

A

oral meds, reduce bp over 24 towards their normal bp

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7
Q

What is the JNC definition of pre-HTN? How often does it need to be checked?

A
  1. SBP: 120-139 mm Hg
  2. DBP 80-89 mm Hg
  3. BP should be rechecked within 1 year.
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8
Q

What is the JNC definition of stage 1 HTN? How often does it need to be checked?

A
  1. SBP 140-159 mm Hg
  2. DBP 90-99 mm Hg
  3. BP should be rechecked within 2 months.
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9
Q

What is the JNC definition of stage 2 HTN? How often does it need to be checked?

A
  1. SBP >160 mm Hg
  2. DBP >100 mm Hg)
  3. BP should be confirmed and the patient should have follow-up within 1 month.
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10
Q

What is the management for BP higher than JNC stage 2, but less than 200?

A
  1. If BP is >180/110 mm Hg: BP should be confirmed and the patient should have follow-up within 1 week. 2. The EP should consider initiating BP treatment upon discharge from the ED
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11
Q

What is the management for BP > 200?

A
  1. If SBP is >210 mm Hg or DBP >120 mm Hg Confirm BP, initiate antihypertensive treatment upon discharge from the ED, and arrange close follow-up within 1 week.
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12
Q

What is the pathophys of HTN urgency/emergency?

A
  1. Is not very well understood.
  2. An abrupt rise in systemic vascular resistance (SVR) and failure of Autoregulation and two steps in initial disease process.
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13
Q

What is the theory for the pathophys of increases in SVR?

A
  1. Increases in SVR are thought to occur from the release of humoral vasoconstrictors from the wall of a stressed vessel. 2. The increased pressure within the vessel then starts a cycle of endothelial damage, local intravascular activation of the clotting cascade, fibrinoid necrosis of small blood vessels, and the release of more vasoconstrictors. If the process is not stopped, a cycle of further vascular injury, tissue ischemia, and autoregulatory dysfunction
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14
Q

How many end-organs are involved in HTN emergencies?

A
  1. Single-organ involvement is found in approximately 83% of patients.
  2. Two-organ involvement is found in 14% of patients.
  3. Multiorgan involvement (>3 organ systems) is found in approximately 3% of patients
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15
Q

What sxs may be present with HTN emergencies?

A
  1. Cerebral infarction (24.5%),
  2. Pulmonary edema (22.5%),
  3. Hypertensive encephalopathy (16.3%),
  4. Congestive heart failure (12%)
  5. Others:intracranial hemorrhage, aortic dissection, and eclampsia
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16
Q

What is cerebral autoregulation?

A

the inherent ability of the cerebral vasculature to maintain a constant cerebral blood flow (CBF) across a wide range of perfusion pressures.

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17
Q

How is autoregulation affected in pts with HTN?

A
  1. Patients with chronic hypertension can tolerate higher mean arterial pressures (MAP) before they have disruption of their autoregulation system. However, such patients also have increased cerebrovascular resistance and are more prone to cerebral ischemia when flow decreases, especially if blood pressure is decreased into normotensive ranges.
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18
Q

What can rapid rises in bp lead to in the brain?

A
  1. hyperperfusion and increased CBF, which can lead to increased intracranial pressure and cerebral edema
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19
Q

What can chronic HTN lead to in the cv system?

A
  1. increased arterial stiffness, increased systolic BP, and widened pulse pressures.
  2. These factors act to decrease coronary perfusion pressures, increase myocardial oxygen consumption, and lead to left ventricular hypertrophy.
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20
Q

How is the left ventricle affected during HTN emergencies?

A

During hypertensive emergencies, the left ventricle is unable to compensate for an acute rise in systemic vascular resistance. This leads to left ventricular failure and pulmonary edema or myocardial ischemia.

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21
Q

What does the pe in an HTN pt need to focus on?

A

The physical examination should assess whether EOD is present

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22
Q

How should bp be measured if HTN urgency/emergency is suspected?

A
  1. BP should be measured in both the supine position and the standing position (assess volume depletion).
  2. BP should also be measured in both arms (a significant difference may suggest aortic dissection).
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23
Q

What findings in the EENT exam suggest EOD?

A

The presence of new retinal hemorrhages, exudates, or papilledema suggests a hypertensive emergency.

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24
Q

What findings in the cardiovascular exam suggest EOD?

A
  1. Evaluate for the presence of heart failure.
    A. Jugular venous distension
    B. Crackles
    C. Peripheral edema
25
Q

What findings in the abd exam suggest EOD?

A

Abdominal masses or bruits

26
Q

What findings in the neuro exam suggest EOD?

A
  1. Level of consciousness
  2. Visual fields
  3. Focal neurologic signs
27
Q

What dx studies are needed for a HTN emergency/urgency pt?

A
  1. Electrolytes, BUN, and creatinine levels to evaluate for renal impairment
  2. CBC and smear to exclude microangiopathic anemia
  3. Urinalysis
    A. Dipstick urinalysis (UA) to detect hematuria or proteinuria (renal impairment)
    B. Microscopic UA to detect RBCs or RBC casts (renal impairment)
  4. Optional Studies
    A. Toxicology screen
    B. Pregnancy test
    C. Endocrine testing
28
Q

What imaging studies are needed for a HTN emergency/urgency pt?

A 
1. Chest radiography is indicated in patients with chest pain or shortness of breath. 
A. Cardiac enlargement 
B. Pulmonary edema 
C. Widened mediastinum
2. Head CTand/or brain MRI are indicated in patients with abnormal neurologic examinations or clinical concern for the following: 
A. Intracranial bleeding 
B. Cerebral edema 
C. Cerebral infarction
29
Q

How low should bp be lowered in a htn emergency/urgency? Why?

A
  1. Even in cases of hypertensive emergencies, the BP should not be lowered to normal levels.
  2. Rapid reduction in BP below the cerebral, renal, and/or coronary autoregulatory range results in marked reduction in organ blood flow, possibly leading to ischemia and infarction.
30
Q

What are the general guidelines for MAP lowering in HTN urgency/emergency pts?

A
  1. In general, the MAP should be lowered by no more than 20% in the first hour of treatment. If the patient remains stable, the BP should then be lowered to 160/100-110 mm Hg in the next 2-6 hours. Please note the exceptions to this general rule listed below.
  2. These BP goals are best achieved by a continuous infusion of a short-acting, titratable, parenteral antihypertensive agent along with constant, intensive patient monitoring.
31
Q

When is rapid bp reduction indicated?

A
  1. Hypertensive Encephalopathy.
  2. Acute Ischemic Stroke.
  3. Acute Intracranial Hemorrhage.
  4. Acute Subarachnoid Hemorrhage
  5. Aortic Dissection.
  6. Acute Coronory Syndrome.
  7. Acute Heart Failure.
  8. Cocain Toxicity/Pheochromocytoma.
  9. Preeclampsia/Eclampsia.
32
Q

What are the preferred medications for htn encephalopathy?

A
  1. Labetalol
  2. Nicardipine
  3. Esmolol
33
Q

What are the medications that should be avoided for htn encephalopathy?

A
  1. Nitroprusside

2. Hydralazine

34
Q

What are the treatment guidelines for htn encephalopathy?

A

Reduce mean arterial pressure (MAP) 25% over 8 hours

35
Q

What are the preferred medications for acute ischemic stroke?

A
  1. Labetalol

2. Nicardipine

36
Q

What are the treatment guidelines for acute ischemic stroke?

A

Withhold antihypertensive medications unless the systolic blood pressure (SBP) is >220 mm Hg or the diastolic blood pressure (DBP) is >120 mm Hg

37
Q

What is the bp goal for acute ischemic stroke when the pt is also receiving fibrinolysis?

A

SBP

38
Q

What are the preferred medications for acute intracerebral hemorrhage?

A
  1. Labetalol
  2. Nicardipine
  3. Esmolol
39
Q

What are the medications to avoid for acute intracerebral hemorrhage?

A
  1. Nitroprusside

2. Hydralazine

40
Q

What are the treatment guidelines for acute intracerebral hemorrhage?

A

Treatment based on clinical/radiographic evidence of increased intracranial pressure (ICP). If signs of increased ICP, maintain MAP just below 130 mm Hg (or SBP

41
Q

What are the preferred medications for subarachnoid hemorrhage?

A
  1. Nicardipine
  2. Labetalol
  3. Esmolol
42
Q

What are the medications to avoid for subarachnoid hemorrhage?

A

Nitroprusside

Hydralazine

43
Q

What are the treatment guidelines for subarachnoid hemorrhage?

A

Maintain SBP

44
Q

What are the preferred medications for aortic dissection?

A

Labetalol, nicardipine, nitroprusside (with beta-blocker), esmolol, morphine sulfate

45
Q

What are the medications to avoid for aortic dissection?

A

Avoid beta-blockers if there is aortic valvular regurgitation or suspected cardiac tamponade

46
Q

What are the treatment guidelines for aortic dissection?

A
  1. Maintain SBP
47
Q

What are the preferred medications for ACS?

A

Beta-blockers, nitroglycerin

48
Q

What are the treatment guidelines for ACS?

A

Treat if SBP >160 mm Hg and/or DBP >100 mm Hg. Reduce BP by 20-30% of baseline.

49
Q

When are thrombolytics contraindicated for ACS based on BP?

A

Thrombolytics are contraindicated if BP is >185/100 mm Hg

50
Q

What are the preferred medications for Acute heart failure?

A

Nitroglycerin, enalaprilat

51
Q

What are the treatment guidelines for acute heart failure?

A

Treatment with vasodilators (in addition to diuretics) for SBP ≥140 mm Hg. IV or sublingual nitroglycerin is the preferred agent

52
Q

What is the preferred medication for Cocaine toxicity/pheochromocytoma ?

A

Diazepam, phentolamine, nitroglycerin/nitroprusside

53
Q

What medications should be avoided for cocaine toxicity/pheochromocytoma?

A

Beta-adrenergic antagonists prior to phentolamine administration

54
Q

What are the treatment guidelines for cocaine toxicity and pheochromocytoma?

A
  1. Hypertension and tachycardia from cocaine toxicity rarely require specific treatment.
    A. Alpha-adrenergic antagonists (phentolamine) are the preferred agents for cocaine-associated acute coronary syndromes.
  2. Pheochromocytoma treatment guidelines are similar to that of cocaine toxicity. Beta-blockers can be added for BP control only after alpha-blockade.
55
Q

What are the preferred medications for preeclampsia/eclampsia?

A

Hydralazine, labetalol, nifedipine

56
Q

What are the medications that should be avoided for preeclampsia/eclampsia?

A

Nitroprusside, angiotensin-converting enzyme inhibitors, esmolol

57
Q

What are the treatment guidelines for preeclampsia/eclampsia?

A

In women with eclampsia or preeclampsia, SBP should be

58
Q

What are the preferred medications for perioperative htn?

A

Nitroprusside, nitroglycerin, esmolol

59
Q

What are the treatment guidelines for perioperative htn?

A

Target perioperative BP to within 20% of the patient’s baseline BP, except if there is the potential for life-threatening arterial bleeding. Perioperative beta-blockers are first choice in patients undergoing vascular procedures or in patients with an intermediate or high risk of cardiac complications

Gen Med: Emergency Med (13 decks)

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