Hypertensive emergencies require rapid blood pressure reduction to prevent target organ damage, while hypertensive urgencies only require gradual reduction over 24 hours without end organ involvement. The case study describes a patient presenting with acute pulmonary edema secondary to hypertensive emergency and acute kidney injury. He was intubated and given intravenous nitrates, frusemide and morphine to rapidly reduce blood pressure and relieve pulmonary congestion over several hours.

1. Hypertensive
Lubaina Zainal Abidin
15.11.15

2. Outline..
 Definition
 Approach in ED
 Management
 Case study

4. Definition..
Hypertension is defined as persistent elevation of
systolic BP of ≥ 140mmHg and/or diastolic BP of ≥ 90
mmHg
CPG Management of hypertension. 4th ed.
2013

5. Definition..
Severe hypertension is defined as persistent
elevated SBP >180 mmHg and/or DBP >110 mmHg
 Further classified into:
(a) Asymptomatic
(b) hypertensive urgencies
(c) hypertensive emergencies
CPG Management of hypertension. 4th ed.
2013
Hypertensive crisis

6. Hypertensive Emergency..
 Persistent elevated SBP >180 mmHg and/or DBP
>110 mmHg with target organ damage/complication
 It is the target organ dysfunction rather than the
absolute blood pressure level pre se
 Situations that require immediate blood pressure
reduction to prevent or limit target organ damage
CPG Management of hypertension. 4th ed.
2013
Shirley O. & Peter M. Emergency Medicine. 2nd ed.
2015
Sixth Report of the JNC on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure.
1997

7. The rate of rise of the of the blood pressure
is more important
rather than the absolute level of BP itself

8. Hypertensive Urgency..
 Persistent elevated SBP >180 mmHg and/or DBP
>110 mmHg with no overt acute target organ
damage/complication
 Clinical scenarios with markedly elevated blood
pressure without obvious end-organ dysfunction
CPG Management of hypertension. 4th ed.
2013
Shirley O. & Peter M. Emergency Medicine. 2nd ed.
2015

9. Target Organ Damage

10. Target Organ Damage

11. Clinical presentation..
1. Incidental finding
2. Non-specific symptoms like headache, dizziness,
lethargy
3. Symptoms and signs of acute target organ
damage.
 Eg. acute heart failure, acute coronary syndromes, acute
renal failure, dissecting aneurysm, subarachnoid
haemorrhage and hypertensive encephalopathy.

12. Approach in ED…
 Is the BP reading correct?
 Repeat using manual sphygmomanometer
 Correct cuff size
 Check the other arm
 Recheck about 1 hour later
 Thorough history
 Compliancy to medication

14. Approach in ED…
 Is it a hypertensive emergency?
 Look for evidence of end organ damage
 Neurological examination : altered mental status,
neurological deficit
 Fundoscopy : papilloedema, haemorrage
 CVS : APO, Aortic dissection

15. Approach in ED…
 Bedside investigation
 ECG
 UPT

16. Approach in ED…
 Lab investigation
 FBC
 RP
 Urine FEME
 LFP/ Coag
 CE/ trop T

17. Approach in ED…
 Radiological ix
 CXR
 CT scan (altered mental status)

18. Management
 ABC
 All patient with hypertensive emergency should be
managed in RED ZONE
 Hypertensive urgency may be managed in the
YELLOW ZONE
 Aim: to control BP without compromising circulation
to the end organs

19. Hypertensive urgency
 Initial treatment should aim for about 25% reduction
in BP over 24 hours but not lower than 160/90
mmHg.
 Oral drugs are proven to be effective.
 There is no role for intravenous BP lowering drugs.
 Combination therapy is necessary.

20. Hypertensive Urgency

21. Hypertensive Emergency
 The BP needs to be reduced rapidly.
 It is suggested that the BP be reduced by 25%
depending on clinical scenario over 3 to 12 hours but
not lower than 160/90 mmHg.
 This is best achieved with parenteral drugs.

22. Hypertensive Emergency
 The specific management will depend on the end-
organ systems that affected by the BP
 Aortic Dissection
 Rapidly reduce SBP to 100-120 mmHg within 5-10
minutes
 Beta blocker, IV morphine
 Acute ischaemic stroke
 Anti-HPT is not routinely indicated
 SBP > 220mmHg or DBP >120mmHg

23. Hypertensive Emergency
 Pre – clampsia
 MgSO4
 hydralazine, labetolol, methyldopa
 Acute left ventricular failure/ APO
 IV GTN

24. Case Study..
44 y/o Indonesian gentleman
Non-smoker
Underlying: HPT
– not on proper follow/up
– not on any medication
Presented with:
 1) SOB x 3/7
worsening today
2) cough x 3/7
yellowish sputum
3) fever x 3/7
low grade fever
on and off
 Otherwise:
no PND/ orthopnea / lower limbs swelling
no chest pain

25. Examination
 GCS 15/15 (E4V5M6)
 vital sign:
BP: 253/147(174)
PR: 117
RR: 30
SPO2: 97%
 Lungs: Generalized crepitations

26. Investigation
 ABG: ph 7.11, pco2 27, po2 103, lac 2.4, hco3 8.6
 FBC : hb 5.9 , hct 17.7, plt 354, wcc18.9
 RP : urea 46.4, Na 131, k 5.1, creatinine1787

28. Diagnosis
1) APO secondary to HPT emergency
2) Cover for CAP (curb 3)
3) Severe metabolic acidosis secondary to acute on
CKD (newly diagnosed)

29. Management
 Decided for intubation due to impending
respiratory collapse
 While intubated noted frothy sputum

30. Management
 IVI GTN 5mcg/min
 IV frusemide 40mg stat
Subsequently, Bp 220/135
 IVI GTN increase to 15mcg/ min
 Admit medical ward

31. APO management – Management of heart failure CPG
1) Oxygen – aim of achieving spo2 > 95%.
 Elective ventilation using non invasive positive
pressure ventilation (CPAP or BiPAP) should be
considered early.
 Should the oxygen saturation be inadequate or the
patient develop respiratory muscle fatigue, then
intubation is necessary.

32. 2) Nitrates - are indicated as first line therapy.
 Reduce preload and afterload
 Sublingually or intravenously. The i.v. route is more
effective and preferable.
 Studies have shown that the combination of i.v. nitrate
and low dose frusemide is more efficacious than high
dose diuretic treatment alone.

33.  IVI GTN preparation
 1 amp = 50mg in 10 mls
 1) 50mg dilute in 50cc
 0.3ml/hr = 5mcg/min
 2) 30mg dilute in 50cc
 1ml/hr = 10mcg/min

34. 3) Frusemide – Intravenous (i.v.) frusemide 40 –
100mg.
 Administration of a loading dose followed by a
continuous infusion.
 The dose should be titrated according to clinical
response and renal function.

35. 4) Morphine – i.v. 3 – 5 mg bolus (repeated if
necessary, up to a total maximum of 10mg).
 It reduces pulmonary venous congestion and
sympathetic drive. It is most useful in patients who
are dyspnoeic and restless.

37. Take home message…
 Do not reduce BP rapidly in asymptomatic severe
hypertension.
 Treat hypertensive urgencies with combination oral
therapy targeting BP to reduce by around 25% within
24 hours.
 Treat hypertensive emergencies with intravenous
drugs targeting BP to reduce by around 25% within 3
to 12 hours.

38. References…
 CPG Management of hypertension. 4th ed. 2013
 Shirley O. & Peter M. Emergency Medicine. 2nd
ed. 2015
 CPG Management of heart failure. 2nd ed. 2007