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Emergency lectures - Hypertensive Emergencie
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Emergency lectures - Hypertensive Emergencie

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  • 1 in 3 adults ¾ in developing countries
  • Pts with chronic HTN will likely develop hypertensive emergencies at higher BP than patients who are usually normotensive
  • Meds: OCPs cocaine, renal artery steonsis, cushing disease, coarctation of aorta
  • Usually dbp>120Clinical presentation NOT the number determine intervention in the ER
  • Most common: neuro, heart, eclampsia, dissection
  • When BP is low cerebral vasodilation when high vasoconstriction keeps CPP constant for changes in MAP. Most ppl can autoregular betn MAP 60-150. I ppl who have chronic HTN their lower limit is higher and they cannot keep CPP at normal MAP therefore you should not attempt to return them to normal.reach higher BP before autorgulation is impaired however
  • Causes hemorrhage coma and deathUsually in normotensive people who have sudden rise in BP.Autoregulation breakthrough
  • Aneurysms, blood thinners
  • Most common: neuro, heart, eclampsia, dissection
  • Flame hemorrhages from high intravascular pressures and exudates from infarcts of nerve fibers bc arterioles bc occluded.
  • Most common: neuro, heart, eclampsia, dissection
  • Reduce work on heart and infarct size. Coronary perfusion depends on DBP. Increased LVH, afterload , narrowing of coronaries
  • Diuretics can increased the pressure driven diuresis and increase reninNo BB bc this can cause decreased inotropy and bradycardia
  • Most common: neuro, heart, eclampsia, dissection
  • Nitroprusside can cause CN toxicity in acute RFKidney becomes passively vulnerable to change in BP leading to acute renal ischemia.
  • Most common: neuro, heart, eclampsia, dissection
  • Hydralazine can cause tachycardia. ACEI contraindicated in pregnancy
  • Cocaine use benzos which block central and periphera sympathomimetic outflowPhentolamine is a blocker, don’t use only b blocker
  • If BP is persistently > 180/110 investigateCuff cover 80% armPw chest pain SOB or neuro deficit
  • Most have GI effectsIV meds: Quick onset, quick offsetNitroprusside—gtt. Quick onset, short acting. Vasodilator decreases preload. Nicardipine: Ca channel blocker gttLabetalol: a 1 and non selective b blocker lasts hours so need less monitoring useful in cerebral pts bc does not affect brain vessels as much, a and b blockerEsmolol: aortic dissection, lasts 20 min cardio selective b blocker. Decreased BP and HRReduce MAP 20-25% over 1 to 2 hours
  • Have to watch for hypotension cannot reverse easily usually need multiple agents
  • Need 2 measurements to confirm HBP

Transcript

  • 1. Hypertensive EmergenciesSushama A. Saijwani, MD. Boston Medical Center. Department of Emergency Medicine
  • 2. Outline of the talk…. Why should ER doctors care about Hypertension? Blood Pressure Basics Stratification of Hypertensive Patients  UncontrolledSevere HTN  Hypertensive Urgency  Hypertensive Emergency** Assessment of Hypertensive Patients Treatment Disposition
  • 3. Why should we be concerned about Hypertension in the ER?Global burden of hypertension: Analysis of worldwide data. Lancet. 2000: 26% world’s population had HTN 2025: 1.5 billion people2/3 Americans are unaware of their HTN75% BP not well controlledER doctor: treat hypertensive emergencies & follow up
  • 4. Blood Pressure BasicsNIH/Joint National Committee on Hypertension Guidelines
  • 5. Blood Pressure Basics Primary or Essential HTN Unknown Cause 95% Secondary HTN Specific disease or medication5%
  • 6. Stratification of Hypertensive Patients Uncontrolled Severe Hypertension  Chronic uncontrolled hypertension  Long term management NOT acute treatment  Follow up within 1 week Hypertensive Urgency  Increased blood pressure, high risk of developing end organ damage WITHOUT new injury  h/o end organ damage: CHF, UA, TIA, CVA, CRI, hypertensive pregnancy  Treatment 1-2 days  PO meds Hypertensive Emergency  Rapid & Progressive high blood pressure causing end organ damage  Immediate: 1-2 hours  IV meds
  • 7. Hypertensive EmergenciesCerebrovascular Retinopathy  Hypertensive  Malignant Encephalopathy Accelerated HTN  Stroke: Ischemic & Hemorrhagic Renal Crises  Acute Kidney Injury  GlomerulonephritisCardiovascular Crises  ACS  Aortic dissection  CHF Other  Pre/eclampsia  Catecholamine excess
  • 8. Cerebrovascular Hypertensive Crises Cerebral AutoregulationConstant blood flow despite ∆ BP CPP = MAP - ICP Cerebral Perfusion Pressure = Mean Arterial Pressure – Intracranial Pressure Vasospasm, ischemia & edema in parieto occipital areas Fails 25% above/below MAP or change in ICP
  • 9. Cerebral AutoregulationIn chronically hypertensive patients: Need higher BP before autoregulation disrupted BUT More susceptible to ischemia when flow reduced Lower limit is also higher SO DO NOT drop MAP by more than 25%
  • 10. Hypertensive Encephalopathy Cerebral over-perfusion  edema Clinical Diagnosis Symptoms:  HTN, Change in MS, Papilledema, HA, vision changes, seizures, vomiting Mental Status improves with BP lowering
  • 11. Cerebrovascular HTN Crises Ischemic CVA: thrombotic, embolic, hypoperfusion Hemorrhagic Stroke: ICH or SAH Survival of penumbra depends on cerebral perfusion  If we decrease BP too much  less cerebral blood flow BUT  Continued infarction  edema and increased ICP How do we manage HTN so as not to risk extension of the stroke? Only when MAP > 130 SBP >220
  • 12. Hypertensive EmergenciesCerebrovascular Retinopathy  Hypertensive  Malignant Encephalopathy Accelerated HTN  Stroke: Ischemic & Hemorrhagic Renal Crises  Acute Kidney Injury  GlomerulonephritisCardiovascular Crises  ACS  Aortic dissection  CHF Other  Pre/eclampsia  Catecholamine excess
  • 13. Malignant Accelerated Hypertension AA men, renal dx, chronic HTN Endothelial damage & vasculitis Elevated BP & Retinopathy  Papilledema  Flame shaped hemorrhages  Soft exudates  HA, vision changes  Proteinuria, Hematuria, worsening renal function
  • 14. Hypertensive EmergenciesCerebrovascular Retinopathy  Hypertensive  Malignant Encephalopathy Accelerated HTN  Stroke: Ischemic & Hemorrhagic Renal Crises  Acute Kidney Injury  GlomerulonephritisCardiovascular Crises  ACS  Aortic dissection  CHF Other  Pre/eclampsia  Catecholamine excess
  • 15. Acute Coronary Syndrome Increased myocardial demand  Increased mass--LVH  Increased afterload—LV wall tension  Coronary arteries narrow Reduce BP to normal! Rx:  Nitroglycerin: Reduces preload, after load, coronary dilation  β Blockers: Reduces HR
  • 16. Aortic Dissection Intimal tear & extension Mortality 1-2% per hour!! Substernal pain to the back Increased pulse pressure Ischemia to heart, kidney, gut Type A  BP meds & Surgery Type B Medical Mgt Rx: DBP < 110 and lower HR Esmolol & Nitroprusside or Labetalol
  • 17. HTN in Congestive Heart FailureLV overcome by increasing afterload LVH & diastolic dysfunction Pulmonary edema Renin activation
  • 18. HTN in Congestive Heart Failure Acutely symptomatic  nitroprusside infusion  nitro paste  slNG ACEI: captopril Diuretics may not be needed acutely Beta blockers good in CHRONIC CHF but can WORSEN pulmonary edema
  • 19. Hypertensive EmergenciesCerebrovascular Retinopathy  Hypertensive  Malignant Encephalopathy Accelerated HTN  Stroke: Ischemic & Hemorrhagic Renal Crises  Acute Kidney Injury  GlomerulonephritisCardiovascular Crises  ACS  Aortic dissection  CHF Other  Pre/eclampsia  Catecholamine excess
  • 20. Renovascular Hypertensive Crisis Both a cause & target organ Parenchymal:  Renal Artery stenosis  Glomerulonephritis  IgA nephropathy Vascular: Damage impairs autoregulation with changes in BP Rx: Nitroprusside or labetalol
  • 21. Hypertensive EmergenciesCerebrovascular Retinopathy  Hypertensive  Malignant Encephalopathy Accelerated HTN  Stroke: Ischemic & Hemorrhagic Renal Crises  Acute Kidney Injury  GlomerulonephritisCardiovascular Crises  ACS  Aortic dissection  CHF Other  Pre/eclampsia  Catecholamine excess
  • 22. Pre-eclampsia & Eclampsia Pregnancy: 20 weeks - 2 weeks post partum  >140/90 or >30/15mm Hg over baseline BP  Edema  Proteinuria HA, vision changes, low UO HELLP syndrome: Hemolysis, Elevated LFTs, Low Platelets Rx: Hydralazine boluses, B Blockers Eclampsia: Magnesium infusion, delivery
  • 23. Catecholamine Excess Sympathomimetics Drugs that elevate BP  Phenylephrine  Cocaine  Oral contraceptives  Methamphetamine  Careful with B Blockers!  Steroids  NSAIDs MAOIs + Tyramine  Nasal decongestants  TCAs Withdrawal: etoh, clonidine  MAOIs Pheochromocytoma  Increases norepinephrine  Paroxysmal Hypertension  Rx: Phentolamine, Labetalol
  • 24. Assessment of the HypertensivePatientAccurate BP • Arm at the level of the heart • BP in BOTH arms • Manual BP check • Treat pain, hypoxia, urinary retention, toxinsLook for target organ damage • PE: papilledema, hemorrhages, exudates • CV: Increased JVP, rales, • Neuro: mental status, focal deficitsTesting • Renal function, electrolytes, plasma renin, tox screen • ECG, Urinalysis • CXR, CT scan
  • 25. Treatment: IV MedsDrug Onset Duration Side Effects IndicationsVasodilatorsSodium Immediate 1-2 min CN toxicity, Widely usedNitroprusside tachycardia esp in neurologicNicardipine 5-10 min 1-4 h HA, Not CHF tachycardiaNitroglycerin 2-5 min 3-5 min HA Coronary ischemicHydralazine 20 min 3-8 h Tachy, HA eclampsiaAdrenergic InhibitorsLabetalol 5-10min 3-6h AV block, ortho Widely used hypotension Not CHFEsmolol 1-2min 10-20min Hypotension Aortic DissectionPhentolamine 1-2min 3-5min Tachy, HA Catecholamine excess
  • 26. Oral BP meds
  • 27. Treatment: Contraindications! Drug Contraindication ACEI/ARB Pregnancy B/l renal artery stenosis Hyperkalemia Acute Kidney Injury β Blockers High degree Heart Block Bradycardia Obstructive airway disease CHF Cocaine Diuretics Gout AKI Calcium Channel CHF Blocker Pregnancy
  • 28. Disposition? Treat pain, anxiety,  Hypertensive Emergency urinary retention,  Admit for treatment & monitoring hypoxia, toxins Taken BP meds?  Hypertensive Urgency  Known h/o HTN  Expected Compliance  Reversible precipitating cause  Can resume previously effective regimen  Follow up in 1 week  Uncontrolled HTN  Follow up
  • 29. References Adams, J et al Emergency Medicine: Expert Consult p. 703-712 Aggarwal, M, Khan I. Hypertensive Crisis: Hypertensive Emergencies and Urgencies. Cardiology Clinics 2006; 24: 135-146 Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217-223 Phillips R, Greenblatt J, Krakoff L. Hypertensive Emergencies: Diagnosis and Management. Progress in Cardiovascular Diseases 2002;45,1: 33-48 Shayne P, Pitts S. Severely Increased Blood Pressure in the Emergency Department. Ann Emerg Med. 2003;41:513-529 Tintinalli J et al. Emergency Medicine. A comprehensive study guide 6th ed 2006 The McGraw-Hill Companies, Inc.