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PHM 703- Critical Care > Hypertensive Crisis/Urgency/Emergency > Flashcards

Hypertensive Crisis/Urgency/Emergency Flashcards

1
Q

Definition of hypertensive crisis

A

SBP >180mmHg, DBP >120mmHg, or both

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2
Q

Definition of hypertensive urgency

A

acute condition of very high BP without evidence of new or worsening target organ damage

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3
Q

Definition of hypertensive emergency

A

acute condition of very high BP and evidence of new or worsening target organ damage

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4
Q

End-organ dysfunction: CV system

A

acute pulmonary/flash pulmonary edema, acute LV dysfunction, acute MI

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5
Q

End-organ dysfunction: neurological

A

hypertensive encephalopathy, acute intracranial bleeding, cerebral infarction, seizures

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6
Q

End-organ dysfunction: vascular system

A

acute aortic dissection, eclampsia/preeclampsia

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7
Q

End-organ dysfunction: renal

A

AKI

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8
Q

End-organ dysfunction: liver

A

elevated function tests, acute liver failure

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9
Q

End-organ dysfunction: other

A

Retinopathy, retinal hemorrhage

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10
Q

Risk factors for hypertensive crisis

A

Female, obesity, hypertensive/coronary heart disease, presence of a somatoform disorder, higher number of antihypertensive agents at baseline

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11
Q

Common causes of hypertensive crisis

A

Non-adherence

Abrupt withdrawal of certain antihypertensives → rebound HTN: Clonidine, beta-blockers

Substance abuse: Cocaine, amphetamines, ecstasy

DDIs: Serotonin syndrome

Drug-food interactions: Tyramine containing foods with MAOIs

Drug-disease state interactions: NSAIDs, sympathomimetics in patients with HTN

Withdrawal: alcohol, opioids, BZDs

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12
Q

Clinical presentation of hypertensive crisis

A

May appear asymptomatic (urgency) or with evidence of target organ damage (hypertensive emergency)

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13
Q

Symptoms of hypertensive crisis

A

HA, N/V, epistaxis, SOB, chest pain, dizziness, paresthesia, vision changes

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14
Q

Signs of hypertensive crisis

A

focal neurological deficits, crackles on lung auscultation, increased SCr/BUN, LFTs, new/worsening hematuria/proteinuria, EKG changes, changes on fundoscopic examination of the eye, changes on CT of the head (bleed), MRI evidence of CVA

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15
Q

Timing of BP lowering in hypertensive urgency

A

Lower BP slowly over 24-48 hours using PO medication, no need for ICU admission

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16
Q

Timing of BP lowering in hypertensive emergency: 1st hour

A

decrease DBP by 10-15% or MAP by 25% with a goal DBP ≥100mmHg

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17
Q

Timing of BP lowering in hypertensive emergency: hours 2-6

A

SBP 160mmHg and/or DBP 100-110mmHg

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18
Q

Timing of BP lowering in hypertensive emergency: hours 6-24

A

Maintaining above goals from the first 6 hours

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19
Q

Timing of BP lowering in hypertensive emergency: hours 24-48

A

gradually decrease BP to normal outpatient goal

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20
Q

Special considerations: aortic dissection

A

SBP ≤120mmHg within first hour, ideally the first 20 minutes (and HR <60 BPM)

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21
Q

Aortic dissection treatment

A

Esmolol, then a vasodilator (nicardipine, clevidipine, nitroprusside)

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22
Q

Special considerations: ischemic stroke

A

tPA: BP <185/110 before tPA and <180/105 during tPA infusion
No tPA: SBP <220mmHg

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23
Q

Treatment for ischemic stroke

A

Nicardipine, clevidipine, labetalol

Avoid sodium nitroprusside

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24
Q

Special considerations: hemorrhagic stroke

A

SBP >220mmHg: lower with infusion and monitor
SBP 150-220 mmHg: <140mmHg in 60 minutes

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25
Q

Treatment for hemorrhagic stroke

A

Same as ischemic stroke

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26
Q

Special considerations: severe preeclampsia or eclampsia

A

SBP <140mmHg in 60 minutes

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27
Q

Preeclampsia/eclampsia treatment

A

Hydralazine, labetalol, nicardipine

AVOID RAAS INHIBITORS AND SODIUM NITROPRUSSIDE

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28
Q

Vasodilators used in hypertensive crisis/emergency

A

Sodium nitroprusside, NTG, hydralazine

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29
Q

Sodium nitroprusside MoA

A

Breaks down into NO → relaxation/dilation of smooth muscle

Direct venous and arterial vasodilator

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30
Q

Onset of sodium nitroprusside

A

<2 mins

31
Q

Duration of sodium nitroprusside

A

1-10 minutes

32
Q

Sodium nitroprusside dosing

A

0.25-10mcg/kg/min

33
Q

Sodium nitroprusside ADEs

A

Potent hypotension, N/V, muscle twitching

Cyanide toxicity; accumulation occurs most commonly at higher doses (>2mcg/kg/min) and longer treatment duration

34
Q

Sodium nitroprusside pearls

A

Caution in high intracranial pressure, azotemia, CKD

35
Q

NTG MoA

A

NTG converted into NO → activates guanylate cyclase → increase of cGMP in smooth muscle → dephosphorylation of myosin light chains → vasodilation

36
Q

NTG onset

A

Immediate

37
Q

NTG duration

A

3-5 mintues

38
Q

NTG dosing

A

5-200mcg/min IV infusion

39
Q

NTG ADEs

A

Hypotension, HA, methemoglobinemia, tolerance with prolonged use

40
Q

NTG pearl

A

Most often used in situations with coronary ischemia

41
Q

Hydralazine MoA

A

Direct-acting smooth muscle relaxant and acts as a vasodilator primarily in the smooth muscle of the arterial bed

42
Q

Hydralazine onset

A

10-80 minutes

43
Q

Hydralazine duration

A

Up to 12 hours

44
Q

Hydralazine dosing

A

IV bolus: 10-20mg IV q4-6h

45
Q

Hydralazine ADEs

A

Hypotension, tachycardia, flushing, HA

46
Q

Hydralazine pearls

A

Concern with unpredictable PK profile → difficult to assess what the effect will be and how long it will last

Safe in pregnancy

47
Q

Beta-blockers used in hypertensive emergency

A

Labetalol, metoprolol, esmolol

48
Q

Beta-blocker MoA

A

Competitively block the binding of NE and epinephrine to beta-adrenergic receptors

49
Q

Beta-blocker ADEs

A

Hypotension, bradycardia/heart block

50
Q

Labetalol-specific ADE

A

orthostatic hypotension

51
Q

Labetalol onset

A

5-10 minutes

52
Q

Labetalol duration

A

180-360 mins

53
Q

Labetalol dosing

A

Bolus: 10-20mg IV q10min
Infusion: 0.5-2mg/min

54
Q

Labetalol pearls

A

Used in most HTN emergencies
Safe in pregnancy
Caution in acute HF

55
Q

Metoprolol onset

A

5-20 minutes

56
Q

Metoprolol duration

A

120-360 mins

57
Q

Metoprolol dosing

A

Bolus: 5-15mg IV q5-15min

58
Q

Metoprolol pearl

A

Caution in acute HF

59
Q

Esmolol onset

A

1-2mins

60
Q

Esmolol duration

A

10-20mins

61
Q

Esmolol dosing

A

Bolus: 250-500mcg/kg/min
Infusion: 50-100 mcg/kg/min

62
Q

Esmolol pearls

A

Drug of choice in aortic dissection
Caution in acute HF

63
Q

CCBs used in hypertensive emergency

A

Clevidipine, nicardipine

64
Q

CCBs MoA

A

Bind to and block voltage-gated L-type calcium channels found on smooth muscle cells of arterial vessels → vasodilation

65
Q

Clevidipine onset

A

2-4 mins

66
Q

Clevidipine duration

A

5-15 mins

67
Q

Clevidpine dosing

A

1-2mg/hr infusion

68
Q

Clevidipine ADEs

A

Hypotension, HA, tachycardia, hypertriglyceridemia (lipid formulation)

69
Q

Clevidipine pearls

A

Most hypertensive emergencies
Caution in coronary ischemia
CI’ed in soy/egg allergy

70
Q

Nicardipine onset

A

5-10mins

71
Q

Nicardipine duration

A

15-30 minutes

72
Q

Nicardipine dosing

A

2.5-5mg/hr

73
Q

Nicardipine ADEs

A

Hypotension, tachycardia, HA, flushing, local phlebitis

74
Q

Nicardipine pearls

A

Most hypertensive emergencies
Not generally utilized in acute HF
Caution with coronary ischemia

PHM 703- Critical Care (14 decks)

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