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Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
Hypertensive crisis
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Hypertensive crisis

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It is important to recognize patients with Hypertensive Crisis so that appropriate management is timely initiated.

It is important to recognize patients with Hypertensive Crisis so that appropriate management is timely initiated.

Published in: Health & Medicine
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  • 1. HYPERTENSIVE CRISISSYED RAZA
  • 2. OBJECTIVES• 1. What is Hypertensive Crisis ?• 2. Size of the problem• 3. Clinical presentation• 4. Management
  • 3. CASE SCENARIO• 69/M• Chest tightness and shortness of breath• Diabetes – 10 years. Chronic smoker• Not known hypertensive• BP 230/120 mmHg HR 110/mt• CVS – S3 gallop, No murmur.• Chest – Bi-basal fine inspiratory crackles• P/A – Kidneys not ballotable. No RA bruit.• Neuro – fully consciouss , No neuro deficits.
  • 4. Lab• Hb – 9.4• MCV- 84• Creatinine : 2.1 mg/dl• Urine : 3 + protein• Cardiac markers - Normal
  • 5. What would you do next?• 1. 24 hour urinary protein.• 2. 24 hour ambulatory BP• 3. Renal Ultrasound• 4. Fundoscopy
  • 6. What targets organs are Involved?• 1. Brain• 2. Heart• 3.Retina• 4. Kidneys
  • 7. What targets organs are Involved?• 1. Brain• 2. Heart• 3.Retina• 4. Kidneys
  • 8. What is the diagnosis?• 1. Accelerated Hypertension• 2.Malignant Hypertension• 3. Hypertensive Urgency• 4. Hypertensive Emergency
  • 9. AnswerHypertensive EmergencySevere Hypertension where BP is > 180/110mmHg with evidence of target organ damage.1.Retinopathy / Retinal hemorrhage2.Encephalopathy/I.C hemorrhage/ IC tension3.Acute Pulm. Oedema, Myocardialischaemia/Aortic dissection.4. Acute Renal Failure
  • 10. HYPERTENSIVE CRISIS• Approximately 25% of emergency room visitsare due to hypertensive crisis.• BP > 180/110 mmHg• Emergency : Target organ damage.• Urgency : No target organ damage.
  • 11. Common precipitating factors• 1. No regular health checks• 2. Age - elderly• 3.Sub therapeutic treatment• 4. Non adherence to medication.• 5. Lack of family care physician.
  • 12. Signs and SymptomsSymptoms specific to target organ damage• Headache• Neck pain• Blurring of vision• Chest tightness• Shortness of breath• Anuria
  • 13. Lab Work Up• 1.CBC• 2. KFT• 3.Urine Analysis• 4. CXR – Heart/aorta size/ LVF• 5. ECG• 6.Fundoscopy• 7.CT/MRI Brain
  • 14. Management : Basic PrincipleUrgency : Out-patientOral medicationBP reduction 24-48 hoursEmergency : InpatientIntravenousImmediate BP reduction < 25% withinminutes – 1 Hour160/100 : 2-6 hours
  • 15. Intravenous Antihypertensive• Nitroglycerine (5-100 mic/mt)• Sodium Nitroprusside (0.25-10 mic/kg/mt)• Enalaprilat (only ACEI in I/V form, 1.25-5mg)• Nicardipine (2ndgeneration) 5-15 mg/hr• Clevidipine (3rdgeneration)• Esmelol (250-500 mic/kg/mt)• Labetalol (20-80 mg bolus)
  • 16. Oral Drugs for HypertensiveUrgency• Amlodipine 5-10 mg OD – 12 hrly• Captopril 12.5 – 25 mg 6 hrly• Nicardipine 20-30 mg 6-8 hrly• Clonidine 0.2 mg 12 hrly• Labetalol 200-400 mg 8-12 hrly• Lasix 20-40 mg 8-12 hrly
  • 17. Medication of choice• Myocardial Ischemia/ LVF : NTG, Esmolol• Aortic Dissection : Labetalol• Acute Renal Failure : Fenoldopam /Nicardipine• Hyper-adrenergic states : due to sympatho-mimetic drugs : Benzodiazepines.Pheo chromocytoma : Phentolamine
  • 18. • Eclampsia : Labetalol /MagnesiumACEI and ARB contra-indicatedIntracranial Heamorrhage: Aim MAP 130mmHgFirst : LabetololSecond : Sodium Nitroprusside if no raised ICPIf ICP raised : Use Nicardipine.
  • 19. • Labetalol : Alpha selective, Beta non selective• oral/ intravenous• Nicardipine : second generationdihydropyridine.Onset of action 5-20 minutes• Nitroglycerine :• More of Venodilator than arterial dilator.• SE: Headache, Flushing, Tachycardia•
  • 20. • Nitro prussside :Strong veno and arterial vasodilator.rapid onset of action.Risk of thiocyanide toxicity : Hyperreflexiadelerium , psychosis
  • 21. Fenoldopam• Selective dopamine 1 receptor Agonist• Onset of action < 1 minute• Useful in patients with acute renal failure.• Fenoldopam improves urinary output,• Creatine clearance , sodium excretion
  • 22. Use of Captopril• Short acting ACEI• Hypertensive Urgency• Oral and sublingual : 6.25-50 mg• Effect seen within 5-15 minutes• Max reduction of BP in 30 mins• Duration of effect 2-6 hours• S/E : Hyperkalaemia / Angio-edema/dry cough
  • 23. Captopril vs Nifedipine
  • 24. Case• 72/m• Annual physical check-up• Asymptomatic• BP 210/100-110 mmHg
  • 25. What would you examine next?• 1. Fundoscopy• 2. CVS• 3.Neurology examination.• 4. Peripheral pulses
  • 26. ANSWER• 1. Fundoscopy• 2. CVS• 3.Neurology examination.• 4. Peripheral pulses
  • 27. Physical Examination• Fundoscopy – Normal• Systemic Physical Examination – Normal• Lab- Normal• ECG and CXR - NAD
  • 28. What is the diagnosis?• 1. Malignant Hypertension.• 2. Hypertensive Urgency• 3. Hypertensive Emergency• 4. Severe Acute Hypertension.
  • 29. ANSWER• 1. Malignant Hypertension.• 2. Hypertensive Urgency• 3. Hypertensive Emergency• 4. Severe Acute Hypertension.
  • 30. How will you manage the patient?• 1.Admit and start intravenousantihypertensive medication• 2. Treat as OP clinic with orallyantihypertensive• 3. Treat if patient is symptomatic• 4. Just Observe
  • 31. How will you manage the patient?• 1.Admit and start intravenousantihypertensive medication• 2. Treat as OP clinic with orallyantihypertensive• 3. Treat if patient is symptomatic• 4. Just Observe
  • 32. What do the guidelines say?Joint National Committee•Seventh report on Prevention, Detection,Evaluation and Treatment of Hypertensionstates ‘’ Initial goal of therapy in hypertensiveemergencies is to reduce MAP by no more than25% - minutes to 1 hour160/100-110 - 2 to 6 hours<140/90 - 24 to 48 hours
  • 33. Exceptions• Patients with ischemic stroke• Patients with Aortic Dissection• Patients requiring urgent thrombolytictherapy (BP < 180/100 mmHg)
  • 34. Acute Ischemic Stroke• If BP < 220/120 mmHg – only observeUnless end organ damageconcurrent hemorrhageIf SBP > 220 and DBP 120-140 : Labetalol/NicardipineIf DBP > 140 : NitroprussideAim for 10 – 15% reduction over 24 hours
  • 35. Aortic Dissection• BP should be lowered quite aggressively• Goal : systolic BP 100-120 mmHg within 20minutes• Aima. lower BPb. decrease LV contraction so as to decreaseAortic shear stressDOC : labetalol or Esmolol

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