Hypertensive Encephalopathy

Question 0

Differential diagnosis for patient with elevated blood pressures and altered mental status?

Answer 0

Pheochromocytoma, illicit drugs (cocaine and amphetamines)

Question 1

Possible etiology of hypertensive encephalopathy?

Answer 1

Pheochromocytoma

Question 2

Hypertensive encephalopathy can present with what symptoms?

Answer 2

1. Elevated blood pressure
2. Confusion
3. Increased intracranial pressure
4. Seizures

Question 3

Patient with hypertensive encephalopathy: goal of treatment?

Answer 3

Lower diastolic blood pressure between 100-110

Question 4

MEN 2A versus MEN 2B

Answer 4

medullary thyroid cancer, hyperparathyroid, Pheochromocytoma

Mucosal neuromas, medullary thyroid cancer, pheochromocytoma

Question 5

Hypertensive urgency versus hypertensive emergency

Answer 5

No acute end- organ damage versus acute end-organ damage

Question 6

Acute end-organ damage includes?

Answer 6

Hypertensive encephalopathy, myocardial ischemia or infarction, aortic dissection, pulmonary edema

Question 7

Hypertensive crisis? Maybe precipitated by?

Answer 7

Occurs in patients with established history of essential hypertension.

Precipitated by

1. simpathomimetic agents (cocaine)
2. conditions that produce excess sympathetic discharge (clonidine withdrawal)
3. Renovascular disease
4. Pheochromocytoma

Question 8

Pathophysiology of a hypertensive emergency?

Answer 8

1. Increase blood pressure usually leads to endothelial cells releasing nitric oxide to vasodilate
2. Persistent increases in arterial pressure overwhelm endothelial response, leading to decompensation and endothelial injury
3. Cerebral autoregulation is unable to maintain constant pressure leading to edema and microhemorrhages in the brain
4. Symptoms such as lethargy, confusion, headache or vision changes manifest

Question 9

Effective treatment of hypertensive emergency is determined by?

Answer 9

Based on SYMPTOMS, not numerical values

Question 10

Medications used hypertensive emergency? Pros? Cons?

Answer 10

Nitroprusside. Instantaneous and easily titrated. Metabolite may accumulate resulting in cyanide toxicity if given for more than 2 to 3 days

Question 11

Drugs given to decrease acute pulmonary edema?

Answer 11

loop diuretics and vasodilators such as nitroglycerin (to decrease preload)

Question 12

Pheochromocytoma?

Answer 12

Catecholamine producing tumors that arise from chromaffin cells of the adrenal medulla

Question 13

Diagnosed pheochromocytoma by?

Answer 13

24 hour urine collection assayed for metanephrines, Vanillylmandelic acid, free catecholamines

Question 14

Treatment of pheochromocytoma?

Answer 14

1. 24 hour urine collection
2. CT or MRI (or octreotide scan)
3. Give alpha-adrenergic blocking agents (phenoxybenzamine) one week prior to surgery
4. Eat a lot of salt to increase blood volume
   Optionally: give beta blocker (although this can result in the pulmonary edema)

Question 15

Clonidine mechanism of action? Problem with stopping clonidine?

Answer 15

a2-adrenergic agonist used to treat hypertension. Rebound hypertension.

Question 16

Treatment of hypertension stroke patients?

Answer 16

Do not treat due to concern of cerebral hypoperfusion

Question 17

Patient with coronary disease with orthopnea and pedal edema. Hospitalized with a blood pressure of 190/105. Normal ECG and cardiac enzymes. Intravenous Furosemide has been administered. Next step?

Answer 17

Give ACE inhibitor as patient likely has congestive heart feeling. Avoid beta blockers because they will decrease ejection fraction further