Hypertensive Crises Flashcards
Hypertensive Crisis
acute condition of very high blood pressure
- systolic > 180
- diastolic > 120
Hypertensive Urgency
A hypertensive crisis without evidence of new or worsening organ damage
Hypertensive Emergency
A hypertensive crisis with evidence of new or worsening organ damage
Hypertensive urgency: time frame
lower BP slowly during the first 24-48 hrs
no need for ICU admission
Hypertensive emergency: timeline
1st hr: decrease DBP by 10-15% or MAP by 25% with goal of DBP >/= 100
2-6 hrs: SBP 160 and/or DBP 100-110
6-24 hrs: maintain above goals
24-48 hrs: gradually decrease BP to normal outpatient goal
Aortic dissection: definition
a tear that occurs in the inner layer of the aorta. Blood surges through the tear causing the inner and middle layers to separate, normal blood flow slows, and the aorta may rupture
Aortic dissection: BP target/timing
SBP </= 120 within the first hour
HR < 60 BPM
Aortic dissection: IV antihypertensive selection
Beta blocker (esmolol)
Vasodilator (nicardipine, clevidipine, nitroprusside)
Ischemic stroke: definition
blood clot that blocks or narrows an artery of the brain, reducing blood flow causing tissue ischemia/death
Ischemic stroke: BP target/timing
BP < 185/110 before fibrinolytic and < 180/105 during fibrinolytic infusion
if no fibrinolytic: SBP < 220
Ischemic stroke: IV antihypertensive selection
Nicardipine
Clevidipine
Labetalol
Avoid sodium nitroprusside
Hemorrhagic stroke: definition
rupture of a weakened blood vessel causing bleeding into the surrounding brain
Hemorrhagic stroke: BP target/timing
If SBP > 220: lower with infusion and monitor
If SBP 150-220: < 140 within 1 hr
Hemorrhagic stroke: IV antihypertensive selection
Clevidipine
Labetalol
Nicardipine
Avoid sodium nitroprusside
Severe Pre-eclampsia definition
severe new-onset hypertension after 20 weeks gestation (SBP > 160 or DBP > 100) + proteinura
Eclampsia definition
a convulsive condition progressed by pre-eclampsia
SPE or Eclampsia: BP target/timing
SBP < 140 within 1 hr
SPE or Eclampsia: IV antihypertensive selection
hydralazine
labetalol
nicardipine
Avoid: RAAS inhibitors and sodium nitroprusside
Vasodilators:
Sodium nitroprusside
Nitroglycerin
Hydralazine
Sodium nitroprusside
Onset: 2 min
Duration: 1-10 min
Dosing: IV 0.25-10 mcg/kg/min
ADE: hypotension, N/V, muscle twitching, cyanide toxicity with LTU
Pearls: caution in high intracranial pressure and CKD
Nitroglycerin
Onset: immediate
Duration: 3-5 min
Dose: 5-200 mcg/min IV
ADE: hypotension, HA, methemoglobinemia, tolerance with LTU
Pearls: most often used with coronary ischemia
Hydralazine
Onset: 10-80 min
Duration: up to 12 hrs
Dosing: IV bolus 10-20 mg Q4-6H
ADE: Hypotension, tachycardia, flushing, HA
Pearls: not often used due to variable onset, safe for use in pregnancy
Beta blockers used in HTN crises
labetalol
metoprolol
esmolol
Labetalol
Onset: 5-10 min
Duration: 180-360 min
Dosing:
- bolus: 10-20 mg IV Q10 min
- infusion: 0.5-2 mg/min
ADE:
- hypotension
- bradycardia/heart block
- orthostatic hypotension
Pearls:
- most used in HTN emergencies
- safe in pregnancy
- caution in acute HF
Metoprolol
Onset: 5-20 min
Duration: 120-360 min
Dosing: bolus 5-15 mg Q5-15 min
ADE:
- hypotension
- bradycardia/heart block
Pearls:
- caution in acute HF
Esmolol
Onset: 1-2 min
Duration: 10-20 min
Dosing:
- Bolus: 250-500 mcg/kg/min
- infusion: 50-100 mcg/kg/min
ADE:
- hypotension
- bradycardia/heart block
Pearls:
- drug of choice in aortic dissection
- caution in acute HF
DHP Calcium Channel Blockers
Clevidipine
Nicardipine
Clevidipine
Onset: 2-4 min
Duration: 5-15 min
Dosing: 1-2 mg/hr IV infusion
ADE:
- hypotension
- HA
- tachycardia
- hypertriglyceridemia (lipid formulation)
Pearls:
- used in most hypertensive emergencies
- caution with coronary ischemia
- CI with soy/egg allergy
Nicardipine
Onset: 5-10 min
Duration: 15-30 min
Dosing: 2.5-5 mg/hr IV infusion
ADE:
- hypotension
- tachycardia
- HA
- flushing
- local phlebitis
Pearls:
- most hypertensive emergencies
- not generally used in acute HF
- caution with coronary ischemia
Enalaprilat
IV ACE inhibitor
Onset: 15-30 min
Duration: 360-720 min
Dosing: 1.25-5 mcg IV Q6H
ADE: hypotension
Pearls:
- caution in acute HF
- avoid in acute MI, eclampsia, and AKI
Fenoldopam
dopamine receptor agonist
Onset: less than 5 min
Duration: 30 min
Dosing: 0.1-0.3 mcg/kg/min IV infusion
ADE:
- hypotension
- tachycardia
- HA
- nausea
- flushing
Pearls:
- avoid in galucoma
