Hypertensive Emergencies

Question 1

Definition of hypertensive crisis?

Answer 1

BP > 180/110 with symptoms or end-organ damage

Question 2

Definition of hypertensive urgency?

Answer 2

BP > 180/110 without symptoms

Question 3

Triad of PRES (Posterior Reversible Encephalopathy Syndrome?

Answer 3

Headache
Altered Mentation
Seizures

Question 4

Dx (PRES)?

Answer 4

MRI with vasogenic edema in parietal and occipital lobes, seen with hyperintenisity on T2-flair.

Question 5

MCC of hypertensive urgency / emergency?

Answer 5

Not taking meds

Question 6

Must exclude as cause of hypterensive urgency / emergency?

Answer 6

-Medication effect (e.g., steroids)
-Toxic ingestion
-Hyperaldosteronism
-Cushing’s
-Pheochromocytoma
-Renal disease

Question 7

Rate of decrease of SBP in HTN-crisis?

Answer 7

-15-20% in the first hour.
-Target 160/100 over next 6 hours
-Normalize over a few days.

Question 8

Side effect of nitroprusside drip?

Answer 8

-Cyanide toxicity (AMS, LA are Sx.

Question 9

Symptoms of cyanide toxicity?

Answer 9

-AMS & LA

Question 10

Toxic levels of cyanide and thiocyante?

Answer 10

-Cyanide = 1mg/L
-Thiocyanate = 10mg/dL.

Question 11

Treatment of cyanide toxicity?

Answer 11

IV Thiosulfate

Question 12

Esmolol: Beta 1 or 2?

Answer 12

Beta-1 selective (cardioselective)

Question 13

Mechanism of action of phentolamine?

Answer 13

Pure alpha-blockade.
-Fast on/off
-Toxicity is fluching & headache

Question 14

Relevant pharmacokinetics of clevidipine?

Answer 14

Ultra-fast DHP-CCB. Off in 1 hour. OK for bad liver/kidney.

Question 15

Relevant pharmacokinetics of fendolopam?

Answer 15

Selective D1 partial agonist. Good for renal failure. Careful w/ glaucoma.

Question 16

Relevant pharmacokinetics of labetalol?

Answer 16

alpha & beta blocker. Lasts 8 hours.

Question 17

BP target w/ intraparenchymal bleed?

Answer 17

SBP 140-150 in first hour.

Question 18

BP target with ischemic CVA?

Answer 18

SBP<185 if received tPA
SBP<220 if not

Question 19

BP targets with ACS & preferred agents?

Answer 19

SBP < 140 in first hour. Use nitroglycerine or BBs.

Question 20

BP targets with acute HF & preferred agents?

Answer 20

SBP < 140 in first hour. Use nitroglycerine, nitroprusside, loop diuretics.

Question 21

BP targets in aortic dissection? Agents to use?

Answer 21

SBP < 120 in first hour. Use esmolol, labetalol & nitroprusside.

Question 22

BP targets in pre-eclampsia?

Answer 22

SBP < 140 in first hour. Use hydralazine, labetalol, CCBs.

Question 23

BP targets in pheochromacytoma or catecholamines?

Answer 23

SBP < 140 in first hour. Use phentolamine.

Question 24

Debakey classification for aortic dissections?

Answer 24

I = including ascending & descending.
II = Just ascending
III = just descending

Question 25

Standford classification for aortic dissection?

Answer 25

A = including ascending +/- descending.
B = only descending.

Question 26

Treatment for stanford A aortic dissection?

Answer 26

Surgical emergency.

Question 27

Treatment for standford B aortic dissection?

Answer 27

Med management. Endovascular stents for those with complications. SBP < 120. HR < 70. Use esmolol or nicardipine/nitroprusside.

Question 28

Dx of pre-eclampsia?

Answer 28

-20 weeks gestation
-BP > 160/110 is severe; > 140/90 makes diagnosis.
-Proteinuria or other end-organ dysfunction. (Protein:Cr>0.3, Plts<100, AKI, LFTs, dyspnea, AMS).

Question 29

Treatment of pre-eclampsia?

Answer 29

SBP < 140; use labetalol, hydralazine, CCBs. Use IV Mg. Delivery of fetus or C-section if less than 32 weeks.

Question 30

Important ddx of pre-eclampsia with AMS?

Answer 30

PRES

Question 31

Name 4 different ways to get catecholamine excess.

Answer 31

1. Cocaine.
2. Meth
3. Pheochromacytoma
4. MAOI + Tyramine (smoked wines, cheese, wine, etc)

Question 32

BP targets with hypertensive encephalopathy?

Answer 32

Decrease by 15-20% in first hour, then 160/110 in next 6 hours.