Management of Hypertensive Emergency

1. PREPARED BY DR.GIRMAWI.M
EM-1
HYPERTENSIVE
EMERGENCY
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2.  Definition
 Epidemiology
 Path physiology
 Diagnosis
 Investigation
 Treatment
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3. Hypertensive emergency is an acute elevation of blood
pressure (180/120 mm Hg) associated with end-organ
damage, specifically, acute effects on the brain, heart, aorta,
kidneys, and/or eyes.
Hypertensive urgency is a clinical presentation associated
with severe elevations in blood pressure without progressive
target organ dysfunction.
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4. Hypertension is the most common modifiable risk factor for
cardiac morbidity and mortality.
Affects approximately 30% of the U.S. population.
It is estimated that 1% to 2% of patients with a history of
hypertension will develop a hypertensive emergency.
Acute hypertensive emergencies are found most commonly
in patients with known hypertension who fail to adhere to
the antihypertensive therapy regimen.
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5. JNC-7 Classification of Hypertension
Class Systolic BP(mmHg) Diastolic BP(mm Hg)
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 140-159 or 90-99
Stage 2 ≥160 or ≥100
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6.  Hypertensive encephalopathy
 Intracerebral haemorrhage
 Stroke
 Acute Coronary Syndrome
 Aortic dissection
 Eclampsia
 Acute renal failure
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9. Distinguish Aortic Dissection from Acute coronary
syndrome.
Acute aortic dissection presents with
 Abrupt, severe onset of pain (90% of cases),
 Usually in the chest (78% of cases),
 Described as tearing or ripping, and
 Radiating to the interscapular.
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10.  ON Physical Examination
 Only 31% have pulse deficits,
 28% have a diastolic murmur, and
 17% have neurologic deficits.
 Chest radiograph is abnormal in 90%, but radiographic signs
are multiple and not specific for aortic dissection (
 Abnormal aortic contour,
 Pleural effusion,
 Displaced intimal calcification, or
 Wide mediastinum).
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11. ECG; (up to 25% have Ecg)
 4% have ST elevation in two or more contiguous leads,
 9% have ST depression, and the remaining
 13% have new T-wave changes.
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12.  Medication with a negative inotropic effect must be given
initially(short acting B-Blockers are Ideal)
 IV Metoprolol,
 IV Esmolol,
 IV Labetalol
 Vasodilators such as Nitroprusside may be added for further
antihypertensive treatment after successful administration of a
negative inotrope.
 Calcium channel blockers may be used in the event of a
contraindication to B-blockade
Calcium channel blockers may be used in the event of a contraindication to -blockade
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13. Pain control with Opioid.
Therapeutic Goal
 Lower systolic Blood Pressure Between 100-120mmHg
 Decrease PR to <60 beats/Min
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14. Patients presenting with severely elevated
blood pressure and ischemic changes
on ECG should be treated with
sublingual or intravenous.
IV β-blockade is only recommended for patients presenting
with severe hypertension.
Oral β-blockade IS remains part of early care.
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16.  Elevated blood pressure associated with sudden onset of
headache, neurologic deficit, or altered mental status suggests
 Hypertensive Encephalopathy
 Subarachnoid Hemorrhage
 Intracerebral Hemorrhage
 Ischemic Stroke
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17. Defined as a change in sensorium or seizure from the
Elevation.
Appropriate agents for the management of hypertensive
encephalopathy include intravenous
 Nicardipine,
 Labetalol,
 Fenoldopam, and
 Clevidipine.
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18. Therapeutic Goal
 Decrease MAP 20%–25% in the first hour of presentation;
more aggressive lowering may lead to ischemic infarction
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19. Recommended agents include IV
 Nicardipine,
 Labetalol,
 Esmolol
 Clevidipine
Oral Nimodipine is a good choice for those with modest
blood pressure elevations because it lowers blood pressure
and reduces vasospasm and subsequent cerebral infarction
rates, improving neurologic.
Subarachnoid Hemorrhage
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20. TherapeuticGoal
 SBP <160 mm Hg to prevent re bleeding; avoid hypotension
to preserve cerebral perfusion;
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21. The treatment of hypertension in patients with intracerebral
hemorrhage includes
 Labetalol,
 Nicardipine, and
 Esmolol.
Therapeutic Goal
 For patients with any evidence of potential elevation of ICP,
treat elevated BP to target MAP of 130 mm Hg.
 If there is no clinical suspicion of elevated ICP, treat to MAP
of 110 mm Hg, or SBP of 160/90mmHg.
Intracerebral Hemorrhage
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22.  Recommended agents are Intravenous
 Labetalol and
 Nicardipine
 Degree of blood pressure reduction depend on whether the
patient is a candidate for reperfusion therapy.
Ischemic Stroke
Treat if >220/120 mm Hg on third of three measurements, spaced 15 min apart.
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TherapeuticGoal
 If fibrinolytic therapy planned, treat if >185/110 mm Hg.
 If fibrinolytic therapy not planned Treat if >220/120 mm
Hg on third of three measurements, spaced 15 min apart.

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25. Patients with new-onset renal failure may have peripheral
edema, oliguria, loss of appetite, nausea and vomiting,
orthostatic changes, or confusion.
Recommended are Intravenous
• Fenoldopam,
• Labetalol
• Nicardipine, and
• Clevidipine
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26.  Fenoldopam is considered by some to be a first-line agent
because it improves natriuresis and creatinine clearance in
patients with elevated blood pressure and impaired renal
function.
 Therapeutic Goal
 Reduction of BP by no more than 20% acutely.
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27. Patients with preeclampsia present later in pregnancy with
edema and proteinuria, but may develop hemolysis, elevated
liver enzyme levels, and low platelet counts.
Recommended agents are
• Labetalol
• Nifidipine
Therapeutic Goal
• Lower BP <160/110
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29. Patients with sympathetic crisis present with symptoms
typical of the underlying mechanism.
Signs of pheochromocytoma include headache, alternating
periods of normal and elevated blood pressure, tachycardia,
and flushed skin, punctuated by asymptomatic periods.
Recommended agent
 IV/IM Phentolamine
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30. Signs of recreational use of cocaine, Amphetamines, or
phencyclidine include tachycardia, diaphoresis, and
hypertension, with or without mental status changes.
Recommended agent
 First line ; IV benzodiazepine; (Lorazepam or Diazepam)
 Second line ; Nitroglycerin, Phentolamine,
 Third line ; Calcium channel–blocking agents (Nicardipine)
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31. Therapeutic Goal
 Reduction of excessive sympathetic drive.
 Symptom relief
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32.  Marked hypertension may accompany acute pulmonary edema
(hypertensive pulmonary edema).
 The pathophysiology is not well defined.
 Recommended agent are
 Nitrate with diuretic
 Nicardipine in patients with systolic dysfunction has a favorable
effect on coronary blood flow.
 B -blockers if the episode of hypertensive pulmonary edema is
clearly a result of acute coronary syndrome or atrial fibrillation with
rapid ventricular response.
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33. TherapeuticGoal
 Reduction of BP by 20%–30%.
 Promotion of diuresis after vasodilation.
 Symptomatic relief.
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34. Acute postoperative hypertension typically begins within 2
hours of surgery and resolves by 6 hours after surgery.
It is more common with vascular procedures and is
associated with serious neurologic, cardiovascular, and
surgical site complications.
Recommended agent
 Nicardipine,
 Labetalol,
 Esmolol,
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35. Pain and Anxiety should be controlled prior to, or in
concert with, blood pressure reduction as needed
TherapeuticGoal
 Consider Preoperative BP for threshold to treat, but mild
elevation is acceptable.
 BP<180/110 mm Hg is a general guideline.
 Consider immediate surgical site complications such as
bleeding.
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37. It has never been shown that acute treatment of
asymptomatic severe hypertension prevents or reduces
patient morbidity or mortality.
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40. Recommendations for the referral and outpatient treatment
of patients with persistently elevated blood pressure
readings in the ED who are without evidence of end-organ
damage.
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41.  Recommendations for initial therapy, when deemed indicated, are for either a
thiazide diuretic or an ACE-I in those patients who do not have compelling
indications for other therapies.
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42. Tintinalles 8th Edition
Uptodate 21.2
Rosen
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