HYPERTENSIVE EMERGENCIES Flashcards
Approach to the Critically Ill Hypertensive Emergency
IF Acute elevated blood pressure (>180/120) associated with end organ dysfunction (brain, heart, kidneys, eyes, aorta) initiate treatment
Target 25% reduction of the MAP over the first hour
Complications: Most Common end organ effects
Stroke
Encephalopathy
CHF
Aortic Dissection
MI / Unstable Angina
Intracerebral Hemorrhage
HPI
Cardiac: CP, SOB, Edema
Renal: Polyuria, Hematuria, Edema
CNS: Visual Change, Headache, Nausea, Confusion, Focal Symptoms, Vague dizziness
Risk Factors
Recent Pregnancy / Post Partum, Recent drug use / Withdrawal, NSAIDs, OTCs,
PMHx: Hyperthyroidism, Pheochromocytoma, OSA
Investigations
Creatinine
U/A - proteinuria
BHCG - r/o pre-eclampsia
TSH
ECG - LVH, ischemic changes
CXR - pulm edema, widening mediastinum
Treatment Goals
Lower BP by 25% within first hour
THEN
If stable to 160/100 mmHg over the next 2-6 hrs
THEN
Cautiously to normal during the following 24-48 hrs
HTN Emergency: List 3 Classes
Vasodilators: Nitroglycerins, Sodium Nitroprusside, Hydralazine
B-Blockers: labetolol, esmolol
A-Blockers: Phentolamine, Nicardipine, Enalapril
Acute Aortic Dissection: preferred agents, treatment goals
Esmolol
500 mcg/kg over 1-3 min followed by infusion of 50-200 mcg / kg / min
Labetolol
10 mg IV over 2 min q 5-10 min until HR is achieved or 300 max
THEN
Nitroprusside 0.5-3 mcg / kg / min
HR Target < 60
THEN
SBP Target < 120 within 20 min
Acute Pulmonary Edema / Acute LV Failure: Preferred Agents, Treatment Goals
Nitroglycerin:
0.4 mg 1-2 sprays SL q5min x 3 (if SBP > 90)
OR
patch (0.4-0.8 mg/h)
OR
IV: 5-10 mcg / min, titrate to max 200 mcg/min
Goal: Reduce BP by 20-30%
Stroke: Preferred Agents, Treatment Goals
Preferred Agents:
Labetolol
10 mg IV over 2 min q 5-10 min until HR is achieved or 300 max
Nicardipine
5 mg / hr IV. INcrease by 2.5 mg / h q 15 min to max 15 mg / h
Goals:
If Fibrinolytic Therapy target BP <185/110 mmHg
If NO Fibrinolytic Therapy
BP by 15% in the first 24 hrs IF SBP >220 or DBP > 120
Unstable Angina / Acute MI: Preferred Agents, Treatement Goals
Nitroglycerine:
0.4 mg 1-2 sprays SL q5min x 3 (if SBP > 90)
OR
patch (0.4-0.8 mg/h)
OR
IV: 10 mcg / min, titrate to
Goals: 10% reduction in MAP if normotensive, 20-30% reduction in MAP if hypertensive.
labetolol: 20 mg IV (5-10 mg) with additional doses 20, 40, 80 to total 300 q 10 min
OR
1-2 mg / min
C/I moderate - servere LV Failure with pulm edema, bradycardia (<60), hypotension (<100), poor peripheral perfusion, 2-3 degree HB, reactive airway disease
Intracranial Hemorrhage: Preferred Agents, Treatment Goals
CONSULT NEUROSURGERY FIRST
SBP > 220 mm Hg may consider lowering BP by 20% after consultation
Avoid Rapid Drop
labetolol: 20 mg IV (5-10 mg) with additional doses 20, 40, 80 to total 300 q 10 min
OR
1-2 mg / min
Nicardipine:
5 mg / hr IV. INcrease by 2.5 mg / h q 15 min to max 15 mg / h
SAH: Preferred Agents, Treatment Goals
Treatment Goals: SBP < 140????
labetolol: 20 mg IV (5-10 mg) with additional doses 20, 40, 80 to total 300 q 10 min
OR
1-2 mg / min
Nicardipine:
5 mg / hr IV. INcrease by 2.5 mg / h q 15 min to max 15 mg / h
Nimodipine PO 60 mg q 4 hr reduces vasospasm
HTN Encephalopathy: Preferred Agent, Treatment Goals
labetolol: 20 mg IV (5-10 mg) with additional doses 20, 40, 80 to total 300 q 10 min
OR
1-2 mg / min
Nicardipine:
5 mg / hr IV. INcrease by 2.5 mg / h q 15 min to max 15 mg / h
Hydralazine: 5 mg IV, repeat 5-10 mg q 20 min
Treatment Goal: Reduce MAP by 20-25% or to dBP 100-110 over 1 hour
Pre-Eclampsia: Preferred Agents, Treatment Goals
ANY DBP > 100 = EMERGENCY
Start Magnesium Sulfate IV
Labetolol: 20 mg IV (5-10 mg) with additional doses 20, 40, 80 to total 300 q 10 min
OR
1-2 mg / min
Hydralazine: 5 mg IV, repeat 5-10 mg q 20 min
