S7C61 - Systemic and Pulmonary HTN

Question 1

Hypertensive Emergency

Answer 1

• 180/120 with end-organ damage
• arterial pressure overwhelms the organ’s ability to compensate for increased pressure, triggers mechanical wall stress and endothelial injury leading to permeability, activation of coag cascade and fibrin deposition. Necrosis of arterioles occurs
• examples: Ao dissection, acute pulm edema, MI, ACS, AKI, preeclapsia, HELLP, retinopathy, encephalopathy, SAH, ICH, sstroke, sympathetic crisis

Question 2

Sympathetic crisis

Answer 2

• pheochromocytoma: h/a, fluctuating BP, tachy, flushed, some asymptomatic periods
• signs of drug use: cocaine, amphetamines
• tachy, diaphoresis, HTN, +/- mental status changes

Question 3

Hypertensive Emergency: investigations

Answer 3

• commonly ordered tests are basic metabolic panel, ECG, CXR and urinalysis
• u/a with blood or protein in it identifies nearly all pts with elevated creatinines

Question 4

Aortic dissection

Answer 4

• treat with labetalol or esmolol
• plus nicardipine or nitroprusside once BB already on board (b/c nitroprusside causes reflex tachycardia)
• goal of SBP 100-120

Question 5

Acute hypertensive pulmonary edema

Answer 5

• nitro SL or IV drip
• nitroprusside IV drip
• then diurese after vasodilated

Question 6

Acute MI (hypertension)

Answer 6

• nitro SL or IV drip
• BB (metoprolol or labetalol)

Question 7

Acute sympathetic crisis (cocaine, amphetamines)

Answer 7

• benzo IV
• nitro SL or IV
• phentolamine
• nicardipine IV drip

**unopposed Beta-blockade can cause alpha storm and increase cocaine toxicity

Question 8

Acute renal failure and HTN

Answer 8

• labetalol bolus, may require nicardipine and dialysis
• avoid nitroprusside, avoid ACEi acutely

Question 9

Severe preeclampsia, HELLP, eclampsia

Answer 9

• labetalol bolus
• nifedipine PO (avoid if pt >45yo or known CAD)
• MgSO4 for seizure

Question 10

Hypertensive Encephalopathy

Answer 10

• nicardipine IV
• labetalol IV
• aboid rapid BP manipulation

Question 11

SAH in HTN

Answer 11

• labetalol or esmolol
• nicardipine

Question 12

Beta blockers

Answer 12

• Labetalol: alpha1 inhibitory and beta-blocking effects (alpha is pretty small effect)
• esmolol is short acting amking it safer in pts with severe asthma

Question 13

Labetalol

Answer 13

• bolus 10-20mg (0.25mg/kg) IV over 2min
• give NMT 300mg total dose via boluses
• infusion 2mg/min and titrate up to 300mg total

Question 14

Esmolol

Answer 14

• load with 250-500mcg/kg over 1-2min
• infusion 50mcg/kg/min over 4min

Question 15

NIcardipine

Answer 15

• infusion at 5mg/h, increase q15min by 2.5mg/h
• max is 15mg/h
• 2nd gen dihydropyridine CCB with vascular selectivity for the cerebral and coronary arteries
• use caution in decompensated heart failure
• avoid if pt receiving IV BB
• SE: h/a, HoTN, vomiting, tachy

Question 16

NItroglycerin

Answer 16

• SL 0.4mg
• paste 1-2inches
• infusion: start with 5mcg/min, increase by 5mcg/min q3-5min to 20mcg/min, if no response at 20mcg/min then increase by 10mcg/min q3-5min up to 200mcg/min
• avoid concurrent use with phosphodiesterase 5 inhibitors

Question 17

NItroprusside

Answer 17

• infusion 0.3-0.5mcg/kg/min IV, increase by 0.5mcg/kg/min
• be aware of cyanide poisoning

Question 18

Pulmonary HTN

Answer 18

• Sx: dyspnea, c/p, syncope
• dx: >25mmHg pulmonary artery pressure at rest or >30mmHg with effort
• 5 groups

1. pulmonary arterial HTN - assoc with a variety of d/o that share common pathophys and response to tx
2. assoc with d/o characterized by LV dz including valvulopathies (starts with incr pulm venous pressure and spreads to pulm artery)
3. assoc with rep derangements or hypoxemia
4. due to chronic thrombosis or embolism
5. miscellaneous