Mr. Rahul, a 52-year-old male with a history of hypertension, bilateral renal artery stenosis, and dyslipidemia, presented to the emergency room with worsening headache, confusion, numbness on his right side, and blurry vision over the past 12 hours. On examination, his blood pressure was extremely elevated at 230/130 mmHg and he showed signs of mild weakness on his right side.
The working diagnosis for Mr. Rahul is secondary hypertension presenting as a hypertensive emergency. His case requires urgent treatment to lower his blood pressure to prevent end organ damage, with a goal of reducing his blood pressure by 15-20% within the first hour and gradually reaching normal levels within 24
This document provides guidance on the assessment and treatment of arrhythmias presenting in the emergency department. It outlines an approach of first determining hemodynamic stability, then distinguishing between narrow and wide complex tachycardias, and finally determining the specific arrhythmia and appropriate treatment. For unstable patients with any arrhythmia, synchronized direct current cardioversion is recommended. Further treatment is tailored based on whether the arrhythmia has narrow or wide QRS complexes and is regular or irregular.
The document discusses the Law of Discordance for left bundle branch block (LBBB), stating that in a normal LBBB the ST segments should be isoelectric or go in the opposite direction from the dominant part of the QRS. It then outlines the Modified Sgarbossa Criteria for diagnosing STEMI in the presence of LBBB, including concordant ST changes or discordant ST elevation greater than 1/4 the amplitude of the S wave. Finally, it notes that these criteria also apply to ventricular paced rhythms and stresses the importance of documentation for ECG interpretations.
This document provides information on hypertensive emergencies and urgencies, including their classification, evaluation, and management. It defines hypertensive emergencies as severe hypertension with evidence of acute target organ damage, while urgencies involve severe hypertension without organ damage. For emergencies, rapid parenteral treatment is needed to stop organ damage progression while avoiding hypoperfusion. Several parenteral agents are discussed for specific conditions along with their dosing and side effects. The goal is to lower blood pressure gradually to avoid complications. Hypertensive urgencies can often be treated orally as outpatients after initial control.
Bundle branch blocks occur when the left or right bundle branch is blocked, preventing normal conduction of electrical impulses through the ventricles. Right bundle branch block is usually benign but can worsen prognosis in acute myocardial infarction by indicating occlusion of the proximal left anterior descending artery. Left bundle branch block is more serious as it can mask signs of myocardial infarction and worsen prognosis in acute infarction. The Sgarbossa criteria can help diagnose myocardial infarction in the presence of left bundle branch block. Left anterior and posterior hemiblocks involve conduction abnormalities localized to one side of the ventricles.
This document provides information on various types of supraventricular tachyarrhythmias including AV nodal reentrant tachycardia (AVNRT), orthodromic reciprocating tachycardia (ORT), atrial tachycardia, junctional tachycardias, Wolff-Parkinson-White (WPW) syndrome, and atrial fibrillation. It discusses the mechanisms, ECG patterns, symptoms, diagnostic approaches, and management options for these arrhythmias in 1-3 sentences per type of arrhythmia.
Bradyarrhythmias are caused by problems with impulse formation in the sinus node or impulse conduction through the AV node. Sinus node dysfunction can cause sinus bradycardia, sinus pause/arrest, or chronotropic incompetence. Atrioventricular block is classified as first, second, or third degree and may be caused by conditions like CAD, drugs, or infiltrative diseases. Second degree AV block is further classified as Mobitz type I or II based on PR interval characteristics. Third degree AV block causes complete dissociation between atrial and ventricular rhythms.
1. Chronic coronary syndromes (CCS) refer to conditions involving atherosclerotic plaque buildup in the coronary arteries that can cause various clinical presentations depending on the dynamic nature of the disease process.
2. The most common clinical scenarios in patients with suspected or established CCS involve those with stable angina symptoms, new onset of heart failure, recent acute coronary syndrome, or asymptomatic patients more than 1 year after initial diagnosis or revascularization.
3. Evaluation and management of patients with suspected CCS involves assessing symptoms, risk factors and comorbidities, performing basic testing, estimating pre-test probability of CAD, selecting appropriate non-invasive testing to confirm diagnosis when needed, calculating risk, and determining long-
Hypertensive crisis is defined as a severe increase in blood pressure that requires prompt treatment to prevent end organ damage. There are two categories: hypertensive urgency, where blood pressure is elevated but there is no acute organ damage; and hypertensive emergency, where elevated blood pressure is associated with acute organ damage. Patients with hypertensive urgency can be treated orally to lower blood pressure by 25% over 24 hours, while those with emergency require rapid intravenous treatment to lower it by 10-25% within minutes to hours. Rapid reduction of blood pressure should be avoided to prevent ischemic events.
This document provides guidance on the assessment and treatment of arrhythmias presenting in the emergency department. It outlines an approach of first determining hemodynamic stability, then distinguishing between narrow and wide complex tachycardias, and finally determining the specific arrhythmia and appropriate treatment. For unstable patients with any arrhythmia, synchronized direct current cardioversion is recommended. Further treatment is tailored based on whether the arrhythmia has narrow or wide QRS complexes and is regular or irregular.
The document discusses the Law of Discordance for left bundle branch block (LBBB), stating that in a normal LBBB the ST segments should be isoelectric or go in the opposite direction from the dominant part of the QRS. It then outlines the Modified Sgarbossa Criteria for diagnosing STEMI in the presence of LBBB, including concordant ST changes or discordant ST elevation greater than 1/4 the amplitude of the S wave. Finally, it notes that these criteria also apply to ventricular paced rhythms and stresses the importance of documentation for ECG interpretations.
This document provides information on hypertensive emergencies and urgencies, including their classification, evaluation, and management. It defines hypertensive emergencies as severe hypertension with evidence of acute target organ damage, while urgencies involve severe hypertension without organ damage. For emergencies, rapid parenteral treatment is needed to stop organ damage progression while avoiding hypoperfusion. Several parenteral agents are discussed for specific conditions along with their dosing and side effects. The goal is to lower blood pressure gradually to avoid complications. Hypertensive urgencies can often be treated orally as outpatients after initial control.
Bundle branch blocks occur when the left or right bundle branch is blocked, preventing normal conduction of electrical impulses through the ventricles. Right bundle branch block is usually benign but can worsen prognosis in acute myocardial infarction by indicating occlusion of the proximal left anterior descending artery. Left bundle branch block is more serious as it can mask signs of myocardial infarction and worsen prognosis in acute infarction. The Sgarbossa criteria can help diagnose myocardial infarction in the presence of left bundle branch block. Left anterior and posterior hemiblocks involve conduction abnormalities localized to one side of the ventricles.
This document provides information on various types of supraventricular tachyarrhythmias including AV nodal reentrant tachycardia (AVNRT), orthodromic reciprocating tachycardia (ORT), atrial tachycardia, junctional tachycardias, Wolff-Parkinson-White (WPW) syndrome, and atrial fibrillation. It discusses the mechanisms, ECG patterns, symptoms, diagnostic approaches, and management options for these arrhythmias in 1-3 sentences per type of arrhythmia.
Bradyarrhythmias are caused by problems with impulse formation in the sinus node or impulse conduction through the AV node. Sinus node dysfunction can cause sinus bradycardia, sinus pause/arrest, or chronotropic incompetence. Atrioventricular block is classified as first, second, or third degree and may be caused by conditions like CAD, drugs, or infiltrative diseases. Second degree AV block is further classified as Mobitz type I or II based on PR interval characteristics. Third degree AV block causes complete dissociation between atrial and ventricular rhythms.
1. Chronic coronary syndromes (CCS) refer to conditions involving atherosclerotic plaque buildup in the coronary arteries that can cause various clinical presentations depending on the dynamic nature of the disease process.
2. The most common clinical scenarios in patients with suspected or established CCS involve those with stable angina symptoms, new onset of heart failure, recent acute coronary syndrome, or asymptomatic patients more than 1 year after initial diagnosis or revascularization.
3. Evaluation and management of patients with suspected CCS involves assessing symptoms, risk factors and comorbidities, performing basic testing, estimating pre-test probability of CAD, selecting appropriate non-invasive testing to confirm diagnosis when needed, calculating risk, and determining long-
Hypertensive crisis is defined as a severe increase in blood pressure that requires prompt treatment to prevent end organ damage. There are two categories: hypertensive urgency, where blood pressure is elevated but there is no acute organ damage; and hypertensive emergency, where elevated blood pressure is associated with acute organ damage. Patients with hypertensive urgency can be treated orally to lower blood pressure by 25% over 24 hours, while those with emergency require rapid intravenous treatment to lower it by 10-25% within minutes to hours. Rapid reduction of blood pressure should be avoided to prevent ischemic events.
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Pulmonary hypertension is defined as a mean pulmonary arterial pressure of at least 25 mm Hg. It can be caused by various conditions and is classified accordingly. Idiopathic pulmonary hypertension has no known cause. It presents with dyspnea and right heart failure. Diagnosis involves right heart catheterization showing elevated pulmonary pressures. Treatment includes diuretics, vasodilators like calcium channel blockers, endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and sometimes atrial septostomy or lung transplantation for severe cases refractory to medical therapy. Prognosis depends on factors like functional status, hemodynamics, and response to treatment.
This document discusses antiplatelet therapy and P2Y12 platelet inhibition. It notes that dual antiplatelet therapy with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel, or ticagrelor is the standard treatment for patients with acute coronary syndrome. It reviews the mechanisms of action and pharmacological properties of different antiplatelet drugs. It also summarizes key trials that have evaluated antiplatelet therapies and provides recommendations from guidelines on treatment selection and duration based on a patient's risk of bleeding and thrombosis.
This document discusses paroxysmal supraventricular tachycardia (PSVT), which represents a subset of supraventricular tachycardias (SVTs) characterized by abrupt onset and termination of a regular, rapid tachycardia. The main types of PSVT are atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) involving an accessory pathway. The document provides details on the mechanisms, clinical presentations, evaluations and management of these arrhythmias. Vagal maneuvers and adenosine are first-line treatment options that can terminate the tachycardias by slowing conduction through the at
(1) The document discusses the evaluation, classification, and treatment of hypertensive emergencies and urgencies. It defines the differences between the two conditions and outlines the goals and approaches for treating each.
(2) For hypertensive urgencies, the goal is to lower blood pressure within several hours to prevent further increases without causing too rapid of a drop. For emergencies, the goal is to reduce blood pressure more quickly to prevent end-organ damage, while maintaining adequate perfusion.
(3) Several intravenous antihypertensive drugs are discussed as options for treatment in hypertensive emergencies, including nitroprusside, nicardipine, labetalol, and
This document summarizes guidelines for treating hypertensive emergencies and urgencies. It defines hypertensive crisis as a severe elevation in blood pressure (>180/120 mmHg) and differentiates between emergencies and urgencies based on whether there is evidence of impending or progressive target organ dysfunction. The goal in treating hypertensive urgencies is to reduce mean arterial pressure by 10-15% within hours using oral medications. Hypertensive emergencies require more rapid blood pressure reduction, typically using intravenous medications, to prevent or limit end-organ damage. Lifestyle modifications and initial drug choices are outlined based on blood pressure levels and patient risk factors.
The document outlines a presentation on hypertension and hypertensive disorders for allied health workers. It begins with an introduction and outline covering hypertension and hypertensive disorders of pregnancy. The outline discusses risk factors and diagnosis of hypertension, as well as management of hypertensive crisis. Guidelines for diagnosing and treating hypertension from sources like the 2020 Philippine CPG are also summarized.
This document defines hypertensive crises and hypertensive encephalopathy. It distinguishes between hypertensive urgency, which is elevated blood pressure without end organ damage, and hypertensive emergency, which is elevated blood pressure with end organ damage. Hypertensive encephalopathy is specifically defined as abrupt elevated blood pressure exceeding cerebral autoregulation limits, causing headaches, confusion, and other neurological symptoms. The pathophysiology involves failure of cerebral blood flow regulation and damage to blood vessels from very high blood pressure. Treatment of hypertensive urgency can be done with oral antihypertensives over 1-2 days, while hypertensive emergency requires rapid parenteral treatment to lower diastolic blood pressure by 25%
This document discusses the classification, causes, symptoms, and treatment of bradycardia. It defines different types of bradycardia based on rhythm and heart block. Common causes include medications, cardiac disease, metabolic abnormalities, and neurological or infectious etiologies. Symptoms range from dizziness to hypotension and shock. Treatment follows ACLS algorithms and may include atropine, transcutaneous pacing, or addressing underlying causes. Case examples demonstrate ECG findings and management of hyperkalemia-induced complete heart block, athlete's heart, and inferior STEMI with complete heart block.
This document discusses hypertensive crisis, which can manifest as either an emergency or urgency depending on the presence of acute or progressive end-organ damage. Hypertensive emergencies require immediate treatment to reduce blood pressure to prevent irreversible organ damage and death. Examples include accelerated or malignant hypertension and hypertensive encephalopathy. Hypertensive urgencies involve elevated blood pressure without symptoms or organ damage, allowing more gradual blood pressure reduction. Proper classification and treatment can improve outcomes for patients experiencing hypertensive crisis.
The presentation covers definitions, identification, Treatment goals, Special situations, Practice points, and cardinal pharmacotherapy. Session presented in NBE learning session
Hypertensive emergencies require immediate blood pressure reduction to prevent end organ damage. They are characterized by severely elevated blood pressure and signs of acute target organ injury. The goal is to lower mean arterial pressure by 20-25% within minutes to hours using intravenous antihypertensive drugs like sodium nitroprusside. Hypertensive urgencies also involve severely high blood pressure but without acute organ injury, allowing for oral drugs to safely lower blood pressure within 24 hours. Rapid blood pressure reduction is avoided to prevent hypotension in both conditions.
This document discusses various non-coronary causes of ST-elevation on electrocardiograms (ECGs) including ventricular aneurysms, pericarditis, early repolarization patterns, left ventricular hypertrophy, left bundle branch block, hypothermia, cardioversion, intraventricular hemorrhage, hyperkalemia, Brugada pattern, type 1C antiarrhythmic drugs, hypercalcemia, pulmonary embolism, hypothermia, myocarditis, and tumor invasion of the left ventricle. It then discusses left ventricular aneurysms, early repolarization, acute pericarditis, hyperkalemia, hypothermia, increased intracranial pressure, Brugada syndrome, Tak
The document provides information on inferior wall myocardial infarction (MI), including:
1. Definitions, epidemiology, etiology, clinical features, diagnosis, treatment and complications of inferior wall MI are discussed. Worldwide over 7 million people experience STEMIs or NSTEMIs annually.
2. Diagnosis involves ECG, cardiac imaging, cardiac biomarkers like troponin and CK-MB. Reperfusion therapy within 6 hours includes PCI or thrombolysis. General treatment measures include aspirin, clopidogrel, anticoagulants, analgesics, beta-blockers, nitrates and oxygen.
3. The history of pioneers in cardiology and development of techniques like echocardi
1. Regional stroke centers should be established to provide thrombolysis and transport to endovascular treatment centers. Every hospital should have a stroke team and protocols for emergency evaluation.
2. Patients should receive IV alteplase as quickly as possible if eligible. Mechanical thrombectomy is recommended for large vessel occlusions within 6-24 hours of onset depending on criteria.
3. In-hospital prevention includes antiplatelet therapy, vascular imaging, and lipid management with statins to reduce cardiovascular risk.
A 45-year-old female presented with difficulty breathing, palpitations, and sweating for 4 hours. An ECG showed Wolff-Parkinson-White (WPW) syndrome, characterized by a short PR interval, delta wave, and widened QRS complex. WPW is a congenital condition involving an accessory pathway that allows supraventricular impulses to bypass the AV node and activate the ventricles early. Treatment options include antiarrhythmic drugs or radiofrequency ablation to destroy the accessory pathway.
CHA2DS2-VASc, Score CHADS2 score, and Hasbled scoreDJ CrissCross
The CHADS2 scoring system is a clinical prediction rule used to assess the risk of stroke in patients with non-rheumatic atrial fibrillation. It assigns points based on various risk factors, with a higher total score indicating greater risk of stroke. It is used to determine if anticoagulation therapy is required. The HAS-BLED scoring system evaluates bleeding risk for patients on oral anticoagulants for atrial fibrillation by assigning points for different risk factors, with a score of 3 or more indicating increased risk of major bleeding within one year.
This document summarizes a presentation on hypertension given by Aanshika Tiwari. It defines hypertension as a blood pressure above 140/90 mmHg. It describes the types, causes, risk factors, signs and symptoms, diagnosis, and treatment of hypertension. Regarding treatment, it discusses both non-pharmacological options like lifestyle modifications as well as various classes of antihypertensive drugs. It also addresses hypertension management in dentistry.
This document discusses hypertension and hypertensive emergencies. It begins with an introduction to hypertension, defining it as elevated blood pressure on 3 or more occasions. It notes the high prevalence of hypertension in Malawi.
It then discusses factors that influence the consequences of blood pressure levels, including age, race, glucose levels, and smoking. It also lists potential secondary causes of hypertension like renal disease.
The document goes on to define categories of hypertension from mild to malignant based on blood pressure levels. It distinguishes between hypertensive emergencies, where immediate treatment is needed to prevent end organ damage, hypertensive urgencies with slightly lower blood pressures, and chronic hypertension without symptoms. It provides guidelines for evaluating
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Pulmonary hypertension is defined as a mean pulmonary arterial pressure of at least 25 mm Hg. It can be caused by various conditions and is classified accordingly. Idiopathic pulmonary hypertension has no known cause. It presents with dyspnea and right heart failure. Diagnosis involves right heart catheterization showing elevated pulmonary pressures. Treatment includes diuretics, vasodilators like calcium channel blockers, endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and sometimes atrial septostomy or lung transplantation for severe cases refractory to medical therapy. Prognosis depends on factors like functional status, hemodynamics, and response to treatment.
This document discusses antiplatelet therapy and P2Y12 platelet inhibition. It notes that dual antiplatelet therapy with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel, or ticagrelor is the standard treatment for patients with acute coronary syndrome. It reviews the mechanisms of action and pharmacological properties of different antiplatelet drugs. It also summarizes key trials that have evaluated antiplatelet therapies and provides recommendations from guidelines on treatment selection and duration based on a patient's risk of bleeding and thrombosis.
This document discusses paroxysmal supraventricular tachycardia (PSVT), which represents a subset of supraventricular tachycardias (SVTs) characterized by abrupt onset and termination of a regular, rapid tachycardia. The main types of PSVT are atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) involving an accessory pathway. The document provides details on the mechanisms, clinical presentations, evaluations and management of these arrhythmias. Vagal maneuvers and adenosine are first-line treatment options that can terminate the tachycardias by slowing conduction through the at
(1) The document discusses the evaluation, classification, and treatment of hypertensive emergencies and urgencies. It defines the differences between the two conditions and outlines the goals and approaches for treating each.
(2) For hypertensive urgencies, the goal is to lower blood pressure within several hours to prevent further increases without causing too rapid of a drop. For emergencies, the goal is to reduce blood pressure more quickly to prevent end-organ damage, while maintaining adequate perfusion.
(3) Several intravenous antihypertensive drugs are discussed as options for treatment in hypertensive emergencies, including nitroprusside, nicardipine, labetalol, and
This document summarizes guidelines for treating hypertensive emergencies and urgencies. It defines hypertensive crisis as a severe elevation in blood pressure (>180/120 mmHg) and differentiates between emergencies and urgencies based on whether there is evidence of impending or progressive target organ dysfunction. The goal in treating hypertensive urgencies is to reduce mean arterial pressure by 10-15% within hours using oral medications. Hypertensive emergencies require more rapid blood pressure reduction, typically using intravenous medications, to prevent or limit end-organ damage. Lifestyle modifications and initial drug choices are outlined based on blood pressure levels and patient risk factors.
The document outlines a presentation on hypertension and hypertensive disorders for allied health workers. It begins with an introduction and outline covering hypertension and hypertensive disorders of pregnancy. The outline discusses risk factors and diagnosis of hypertension, as well as management of hypertensive crisis. Guidelines for diagnosing and treating hypertension from sources like the 2020 Philippine CPG are also summarized.
This document defines hypertensive crises and hypertensive encephalopathy. It distinguishes between hypertensive urgency, which is elevated blood pressure without end organ damage, and hypertensive emergency, which is elevated blood pressure with end organ damage. Hypertensive encephalopathy is specifically defined as abrupt elevated blood pressure exceeding cerebral autoregulation limits, causing headaches, confusion, and other neurological symptoms. The pathophysiology involves failure of cerebral blood flow regulation and damage to blood vessels from very high blood pressure. Treatment of hypertensive urgency can be done with oral antihypertensives over 1-2 days, while hypertensive emergency requires rapid parenteral treatment to lower diastolic blood pressure by 25%
This document discusses the classification, causes, symptoms, and treatment of bradycardia. It defines different types of bradycardia based on rhythm and heart block. Common causes include medications, cardiac disease, metabolic abnormalities, and neurological or infectious etiologies. Symptoms range from dizziness to hypotension and shock. Treatment follows ACLS algorithms and may include atropine, transcutaneous pacing, or addressing underlying causes. Case examples demonstrate ECG findings and management of hyperkalemia-induced complete heart block, athlete's heart, and inferior STEMI with complete heart block.
This document discusses hypertensive crisis, which can manifest as either an emergency or urgency depending on the presence of acute or progressive end-organ damage. Hypertensive emergencies require immediate treatment to reduce blood pressure to prevent irreversible organ damage and death. Examples include accelerated or malignant hypertension and hypertensive encephalopathy. Hypertensive urgencies involve elevated blood pressure without symptoms or organ damage, allowing more gradual blood pressure reduction. Proper classification and treatment can improve outcomes for patients experiencing hypertensive crisis.
The presentation covers definitions, identification, Treatment goals, Special situations, Practice points, and cardinal pharmacotherapy. Session presented in NBE learning session
Hypertensive emergencies require immediate blood pressure reduction to prevent end organ damage. They are characterized by severely elevated blood pressure and signs of acute target organ injury. The goal is to lower mean arterial pressure by 20-25% within minutes to hours using intravenous antihypertensive drugs like sodium nitroprusside. Hypertensive urgencies also involve severely high blood pressure but without acute organ injury, allowing for oral drugs to safely lower blood pressure within 24 hours. Rapid blood pressure reduction is avoided to prevent hypotension in both conditions.
This document discusses various non-coronary causes of ST-elevation on electrocardiograms (ECGs) including ventricular aneurysms, pericarditis, early repolarization patterns, left ventricular hypertrophy, left bundle branch block, hypothermia, cardioversion, intraventricular hemorrhage, hyperkalemia, Brugada pattern, type 1C antiarrhythmic drugs, hypercalcemia, pulmonary embolism, hypothermia, myocarditis, and tumor invasion of the left ventricle. It then discusses left ventricular aneurysms, early repolarization, acute pericarditis, hyperkalemia, hypothermia, increased intracranial pressure, Brugada syndrome, Tak
The document provides information on inferior wall myocardial infarction (MI), including:
1. Definitions, epidemiology, etiology, clinical features, diagnosis, treatment and complications of inferior wall MI are discussed. Worldwide over 7 million people experience STEMIs or NSTEMIs annually.
2. Diagnosis involves ECG, cardiac imaging, cardiac biomarkers like troponin and CK-MB. Reperfusion therapy within 6 hours includes PCI or thrombolysis. General treatment measures include aspirin, clopidogrel, anticoagulants, analgesics, beta-blockers, nitrates and oxygen.
3. The history of pioneers in cardiology and development of techniques like echocardi
1. Regional stroke centers should be established to provide thrombolysis and transport to endovascular treatment centers. Every hospital should have a stroke team and protocols for emergency evaluation.
2. Patients should receive IV alteplase as quickly as possible if eligible. Mechanical thrombectomy is recommended for large vessel occlusions within 6-24 hours of onset depending on criteria.
3. In-hospital prevention includes antiplatelet therapy, vascular imaging, and lipid management with statins to reduce cardiovascular risk.
A 45-year-old female presented with difficulty breathing, palpitations, and sweating for 4 hours. An ECG showed Wolff-Parkinson-White (WPW) syndrome, characterized by a short PR interval, delta wave, and widened QRS complex. WPW is a congenital condition involving an accessory pathway that allows supraventricular impulses to bypass the AV node and activate the ventricles early. Treatment options include antiarrhythmic drugs or radiofrequency ablation to destroy the accessory pathway.
CHA2DS2-VASc, Score CHADS2 score, and Hasbled scoreDJ CrissCross
The CHADS2 scoring system is a clinical prediction rule used to assess the risk of stroke in patients with non-rheumatic atrial fibrillation. It assigns points based on various risk factors, with a higher total score indicating greater risk of stroke. It is used to determine if anticoagulation therapy is required. The HAS-BLED scoring system evaluates bleeding risk for patients on oral anticoagulants for atrial fibrillation by assigning points for different risk factors, with a score of 3 or more indicating increased risk of major bleeding within one year.
This document summarizes a presentation on hypertension given by Aanshika Tiwari. It defines hypertension as a blood pressure above 140/90 mmHg. It describes the types, causes, risk factors, signs and symptoms, diagnosis, and treatment of hypertension. Regarding treatment, it discusses both non-pharmacological options like lifestyle modifications as well as various classes of antihypertensive drugs. It also addresses hypertension management in dentistry.
This document discusses hypertension and hypertensive emergencies. It begins with an introduction to hypertension, defining it as elevated blood pressure on 3 or more occasions. It notes the high prevalence of hypertension in Malawi.
It then discusses factors that influence the consequences of blood pressure levels, including age, race, glucose levels, and smoking. It also lists potential secondary causes of hypertension like renal disease.
The document goes on to define categories of hypertension from mild to malignant based on blood pressure levels. It distinguishes between hypertensive emergencies, where immediate treatment is needed to prevent end organ damage, hypertensive urgencies with slightly lower blood pressures, and chronic hypertension without symptoms. It provides guidelines for evaluating
Hypertension emergency is characterized by severely elevated blood pressure (>180/120 mm Hg) and evidence of impending organ damage. Hypertension urgency also involves severely elevated blood pressure but without organ damage. The goal of treatment is to gradually lower blood pressure over minutes to hours in emergencies and over 24 hours in urgencies to prevent organ damage. Intravenous drugs are used for emergencies while oral drugs are preferred for urgencies with close monitoring. Specific treatment depends on the underlying cause and affected organs.
This document discusses hypertensive emergencies and urgencies. It defines hypertensive emergency as severe hypertension with acute end-organ damage, requiring rapid BP reduction over hours. Hypertensive urgency is severe hypertension without acute end-organ damage, allowing BP control over days to weeks. The main organs affected are the brain, heart, and kidneys. Initial treatment involves evaluating for end-organ damage and relaxing the patient before considering IV antihypertensives. Goals are to lower BP by 25% over the first hour while maintaining organ perfusion. Specific treatments depend on the damaged organ system. Follow-up after discharge assesses for ongoing hypertension management.
Hypertensive crisis refers to severely elevated blood pressure that can lead to organ damage and is categorized as hypertensive urgency or emergency depending on the presence of end-organ damage; treatment of urgency involves gradual oral medication while emergency requires immediate intravenous drugs to reduce blood pressure to prevent further damage; careful diagnosis and monitoring of blood pressure and organs is needed along with selecting appropriate drugs based on the situation.
Hypertension emergencies require rapid reduction of blood pressure to prevent end organ damage. Hypertensive urgency can be managed as an outpatient but emergencies require hospitalization. Initial evaluation assesses for signs of damage to heart, kidneys, brain, or vasculature. Parenteral drugs like nicardipine, labetalol, and esmolol are used to lower blood pressure 10-15% within 1 hour and further to 160/100 mmHg in 2-6 hours, with goals tailored to specific conditions like stroke, heart failure, or aortic dissection. Oral agents like clonidine or nifedipine may be used after initial parenteral treatment to control blood pressure before discharge
Hypertension emergencies require rapid reduction of blood pressure to prevent end organ damage. Hypertensive urgency can be managed as an outpatient with oral medications, while emergencies require hospitalization and intravenous drugs. Initial evaluation assesses for signs of heart, brain, kidney and vascular damage. Parenteral drugs like nicardipine, labetalol and esmolol are used but sodium nitroprusside is no longer first-line due to risks. Treatment goals depend on the specific organ involved and reduce pressure by 10-25% within 1-2 hours.
Hypertensive urgency and emergency are defined based on whether there is acute end organ damage present. Hypertensive urgency involves severe hypertension without acute end organ damage, while hypertensive emergency involves severe hypertension with acute end organ damage. Accurate blood pressure measurement requires proper technique and positioning. Common forms of acute end organ damage include neurological issues like hypertensive encephalopathy, cardiovascular issues like pulmonary edema, and renal issues like acute kidney injury. Management of hypertensive urgency involves slowly lowering blood pressure over hours to days in a controlled manner to avoid complications, while hypertensive emergency requires immediate treatment to prevent further end organ damage.
This document discusses hypertension including its prevalence in India, definition, methods of blood pressure measurement, screening recommendations, classification, causes of secondary hypertension, complications if uncontrolled, and effects on target organs like the heart, kidneys, eyes, and nervous system. It provides information on accurate blood pressure measurement techniques, definitions of prehypertension, types of hypertensive crises, and non-pharmacological and pharmacological intervention strategies.
This document provides an overview of hypertensive crises, including hypertensive urgency and emergencies. It defines these conditions, discusses their epidemiology, risk factors, pathophysiology, clinical presentation, diagnosis, and management. Hypertensive urgency involves severe blood pressure elevations without end-organ damage, while emergencies involve elevations with end-organ damage. Management of urgency involves gradually lowering blood pressure over hours to days, while emergencies require faster reduction, usually with parenteral drugs initially then oral medications. Follow up care aims to identify and treat underlying causes while achieving long-term blood pressure control.
This document provides an overview of hypertensive crises, including hypertensive urgency and emergencies. It defines these conditions, discusses their epidemiology, risk factors, pathophysiology, clinical presentation, diagnosis, and management. Hypertensive urgency involves severe blood pressure elevations without end-organ damage, while emergencies involve elevations with end-organ damage. Management of urgency involves gradually lowering blood pressure over hours to days, while emergencies require faster reduction, usually with parenteral drugs initially then oral medications. Follow up aims to identify and treat underlying causes, and ensure blood pressure is well-controlled to prevent recurrence.
This document provides an overview of hypertensive crises, including hypertensive urgency and emergencies. It defines these conditions, discusses their epidemiology, risk factors, pathophysiology, clinical presentation, diagnosis, and management. Hypertensive urgency involves severe blood pressure elevations without end-organ damage, while emergencies involve elevations with end-organ damage. Management of urgency involves gradually lowering blood pressure over hours to days, while emergencies require faster reduction, usually with parenteral drugs initially then oral medications. Follow up aims to identify and treat underlying causes while achieving blood pressure control to prevent recurrence.
Mr. A is a 61-year-old retired police officer who presented with headache and giddiness. His blood pressure was 150/90 mmHg. Tests showed grade 1 hypertension, obesity, impaired glucose tolerance, and dyslipidemia. He has a high cardiovascular risk level. An ACE inhibitor would be an appropriate initial treatment to aim for a target blood pressure of below 140/90 mmHg. Appropriate response would be a reduction in blood pressure of at least 25% over 24 hours without going below 160/90 mmHg. Hypertensive emergencies require rapid blood pressure reduction of 25% over 3-12 hours while monitoring for specific organ involvement.
This document provides information about hypertension management through a series of questions and presentations. It begins with 3 multiple choice questions about hypertension management goals, recommended first-line drugs, and blood pressure staging. The subsequent presentations define blood pressure, discuss white coat hypertension, screening recommendations, hypertension classification, etiology, duration and incidence. It also covers hypertension evaluation, secondary causes, treatment approaches including lifestyle modifications and pharmacotherapy, special patient considerations, and resistant hypertension.
Management of hypertensive condition in 2020 according to AHA/ASA guidelines. We will discuss the presentation, clinical assessment, investigations, and management of hypertension along with major randomized controlled trials and guidelines.
This document discusses managing hypertensive emergencies in the emergency department. It defines hypertension and hypertensive urgency versus emergency. For hypertensive urgency, when BP is markedly elevated but there are no symptoms, treatment is usually not required in the ED and patients can be referred for outpatient follow up. For hypertensive emergency, when there are progressive symptoms of end organ damage, treatment in the ED is warranted to lower BP by about 25% aiming to avoid hypotension. Goals of treatment and commonly used oral and IV antihypertensive agents are reviewed.
This document provides an overview of the management of hypertensive crisis. It begins with definitions of hypertensive urgency and emergency. It then covers etiology, pathophysiology, clinical evaluation, workup, and management. The goals of management are to lower blood pressure gradually in hypertensive urgencies, and more rapidly in emergencies to prevent end organ damage, while avoiding too rapid a drop in pressure. Drugs discussed for acute treatment include sodium nitroprusside, nicardipine, clevidipine, labetalol, and esmolol. Special scenarios like myocardial ischemia and aortic dissection are also addressed.
The document provides information on the management of hypertensive crisis. It begins with outlines of topics covered which include introduction, etiology, pathophysiology, clinical evaluation, workup, and management. It then goes into further detail on these topics. The key points are:
1) Hypertensive crisis is defined as a sudden rise in blood pressure that causes end organ damage and is classified as either a hypertensive urgency or emergency.
2) Common causes include poorly controlled essential hypertension and renal disease.
3) Rapid evaluation is needed to identify end organ damage to the heart, kidneys, brain, or vasculature.
4) Treatment involves slowing lowering blood pressure, usually over hours
This document provides an overview of hypertension, including its causes, symptoms, types, complications, diagnosis, treatment, and management. It discusses essential and secondary hypertension, complications such as heart failure and stroke, diagnostic criteria, lifestyle modifications, drug therapy options including diuretics, beta blockers, ACE inhibitors, and more. Treatment involves lifestyle changes, medication, and monitoring to control blood pressure and reduce complications.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
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Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
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Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
2. Case Scenario
Mr. Rahul, 52yr male presents to emergency room with worsening
headache and confusion, numbness and weakness involving right
side of body and blurry vision for the past 12 hrs.
On examination, pulse is 84/min regular, BP is 230/130mmHg, room
air oxygen saturation 94%, confused & mild motor weakness (4/5)
in the right arm.
2
MCQ following
3. Case Scenario
He is a known case of hypertension, bilateral renal artery
stenosis & dyslipidemia on irregular treatment.
3
4. MCQ No. 1
Working diagnosis of the patient Mr. Rahul can be best
described as:
1. Secondary hypertension presenting as hypertensive
emergency
2. Secondary hypertension presenting as hypertensive
urgency
3. Primary hypertension presenting as hypertensive
emergency
4. Primary hypertension presenting as hypertensive urgency
4
5. Approach
5
• STEP 2
Assess Target Organ Involvement
STEP 1
Assess the severity of hypertension & urgency of treatment
STEP 2
Assess Target Organ Involvement
STEP 3
Send relevant investigation(s)
STEP 4
Treatment Goals
STEP 5
Which Drug (s) to Use
STEP 6
Drugs for Specific Situation
7. Assess the severity of hypertension &
urgency of treatment
Definition:
Prehypertension:
Systolic Blood Pressure120–139 mmHg and
Diastolic Blood Pressure 80–89 mmHg
Hypertension:
Stage 1: 140- 159 mmHg/ 90-99 mmHg
Stage 2: > 160 mmHg/ > 100 mmHg
Hypertensive crisis: Hypertensive urgency or emergency
(Generally > 180/ 110 mmHg)
7
The JNC 8 (2013) Hypertension Guidelines
8. Assess the severity of hypertension &
rapidity of treatment needed
Hypertensive urgency:
Acute rise in blood pressure without acute end-organ damage;
diastolic blood pressure usually >120 mm Hg
Hypertensive emergency:
Acute rise in blood pressure with acute end-organ damage; diastolic
blood pressure usually > 120 mm Hg
8
9. Accelerated hypertension:
Markedly elevated blood pressure is accompanied by target
organ damage (grade 3 retinopathy), but no papilledema
Malignant hypertension:
Markedly elevated diastolic blood pressure (>130 mmHg)
accompanied by papilledema (grade 4 retinopathy)
9
Dropped
terms
10. Causes of hypertensive emergency and urgency
Essential hypertension
• High blood pressure that doesn't have a known secondary
cause
Secondary hypertension
• High blood pressure that's caused by another medical
condition
11. Secondary Causes of Hypertensive Emergency
and Urgency
Cardiovascular
Renal
Central Nervous System
Drugs
Endocrine
Others
20. Clinical features
• History and physical examination
• History—duration and severity of hypertension, previous BP records &
and H/o any anti hypertensive drug
• Relevant symptoms
– Chest pain, dyspnea, edema, acute fatigue
– Epistaxis
– Headache, change in the level of consciousness, seizure, motor
weakness
20
21. Clinical features
• Palpitation, diaphoresis, tremors suggestive of
phaeochromocytoma
• Weight gain, thinning of skin suggestive of Cushing’s
Syndrome
• History of comorbid condition
• Compliance of medication
21
22. Clinical features
• Physical Exam
– Feel all peripheral pulse
– Measure BP in both arms
– Look for JVP, pedal edema, auscltate for crepitation, Gallop and
abdominal bruits
– Focus on areas of potential target-organ damage
- CNS - Heart
- Pulmonary - Renal - Retina
22
26. Common Symptoms of Crisis
Shortness of breath (29%)
Chest pain (26%)
Headache (23%)
Altered mental status (20%)
Focal neurologic deficit (11%)
Microangiopathic hemolysis with reversible renal insufficiency (27%)
26
Jason N. Katz, MD, et al. Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe
hypertension: The Studying the Treatment of Acute hypertension (STAT) Registry. Hypertension. 2009
29. Relevant Investigation
• USG KUB- For structure abnormality like polycystic kidney
disease
• Reanl doppler or renal angiogram- For renal artery stenosis
• Urinary VMA, Metanephrine, 5HIAA – Pheochromocytoma
• Plasma cortisol or dexamethasone suppression test- Cushing
Syndrome
29
30. MCQ No. 2
One of the following is recommended in hypertensive crisis but
least often performed in ICU patients
1. Invasive arterial blood pressure monitoring
2. CT scan even in presence of unilateral weakness
3. Cardiology review if there are changes in ECG
4. Fundoscopic examination and ophthalmology review in
normal vision
30
In STAS Registry only 13% of the patients underwent fundus examination
35. MCQ No. 3
The following is the treatment goals in hypertensive
crisis
1.Reduce blood pressure to 40 % in all by Intravenous drugs
2.Reduce blood pressure to normal within 2 hours in all
patients
3.Only routine oral medication to be resumed
4.Reduce blood pressure 15 to 20 % in one hour then
gradually to normal in 24 to 48 hours
35
36. Treatment
Weigh benefits of decreasing BP against risks of decreasing end-
organ perfusion.
Important steps include:
– Appropriately evaluating patients with an elevated BP
– Correctly classifying the hypertension
– Determining aggressiveness of therapy
An important point to remember in the management of the
patient with any degree of BP elevation is to “treat the patient
and not the numbers.”
36
37. Treatment
Initial considerations:
– Relaxation and de-stress
– Consider the context of the elevated BP (e.g. severe pain)
– Screen for end-organ damage
– No evidence of end-organ effects –Oral medicines –
monitor - discharged with follow–up
37
38. Treatment
Hypertensive urgency:
– Immediate goal—lower blood pressure within 24–72
hours
– Treatment setting—clinical discretion is required
– Medications—oral medications with rapid onset of
action; occasionally intravenously
38
39. Treatment
Hypertensive emergency:
– Immediate goal—lower MAP by 15–20% within 2 hours,
25% within 12 hours, 30% within 48 hours
– Treatment setting—intensive care unit, intra-arterial BP
monitoring
Medications—intravenous
39
41. Treatment
There are 2 main classes of drugs
1.Vasodilators
– Nitroglycerin
– Sodium Nitroprusside
– Fenoldopam
– Hydralazine
– Nicardipine
– Clevidipine
– Enalaprilat
2. Adrenergic inhibitors
– Labetalol
– Esmolol
– Metoprolol
– Phentolamine
41
42. Target Blood Pressure Goal
Hypertensive Emergency Target Blood Pressure
Hypertensive Encephalopathy MAP lowered by maximum20% or DBP 100-110mmHg within first hour then gradual
reduction in BP to normal range over 48-72 hour
Ischemic stroke MAP lowered no more than 15-20%,DBP not less than 100-110mmHg in first 24 hour
Ischemic stroke plan-tPA SBP < 185mmHg or DBP <110 mmHg
Intra cerebral hemorrhage MAP lowered by 20%–25%
Aortic dissection SBP 100–120 mm Hg
42
45. Common Oral Medications for Hypertensive
Urgencies
Drug Dose Onset of Action Side effect
Labetalol 200–400 mg po 20–120 min Bronchoconstriction, heart block, aggravate heart failure
Clonidine 0.1–0.2 mg po 30–60 min Rebound hypertension with abrupt withdrawal
Captopril 12.5–25 mg
Sublingually
15–60 min Can precipitate acute renal failure in setting of bilateral
renal artery stenosis
Nifedipine,
extended
release
30 mg po 20 min Avoid short-acting oral or Sublingual due to risk of stroke,
acute myocardial infarction, severe hypotension
Amlodipine 5–10 mg po 30–50 min Headache, tachycardia, flushing, peripheral edema
Katz JN, Gore JM, Amin A, et al. Practice patterns, outcomes, and end-organ dysfunction for patients with
acute severe hypertension: the Studying the Treatment of Acute hypertension (STAT) registry. Am Heart J
2009; 158:599–606.
45
46. MCQ No. 4
All of the following commonly drop blood
pressure precipitously except:
1. Sodium Nitroprusside
2. Hydralazine
3. Nifedipine
4. Labetalol
46
47. Sublingual Captopril
• Administered sublingually, in which case the
onset of action may occur within 10-20
minutes, with the maximal effect reached
within 1 hour
• Initial Dose 25 mg
47
Amgad HH et al. Evaluation of the clinical outcome of captopril use for hypertensive urgency in
Khartoum State’s emergency centres. African Journal of Emergency Medicine 11 (2021) 202–
206
Tab Angiopril 25 mg
Tab Capotril 25 mg
48. Drug Dose Onset of Action Duration Adverse effects Pearls
Sodium
Nitroprusside
0.25–10 mg/kg/min IV
infusion
Within seconds to
minutes
1-2 min Tachyphylaxis
Muscle twitching
Avoid in renal
failures
Nitroglycerin 5–100 mg/min IV infusion 1–5 min 10–20 min Tachyphylaxis
Tachycardia
Variable response
Hydralazine 10–20 mg IV bolus 10–20 min 3-10 hours Drug induced lupus Unpredictable
effects
Phentolamine 5–15 mg IV bolus 1–2 min 2 – 4 hours Arrhythmia
Bradycardia
Used in adrenergic
crisis
Enalaprilat 1.25–5 mg every 6 h IV
bolus
15–30 min 4 hours Bradycardia
Variable response
Avoid in renal
failure
Parenteral medications used for treatment of hypertensive crisis
48
49. Drug Dose Onset of Action Duration Adverse effects Pearls
Labetalol 20 mg bolus every 10-20
min, Maximum 300 mg
or 0.5–2 mg/min IV
infusion
5–10 min 2-6 hours Bradycardia
Metoprolol 2.5 -20 mg 20 min 3-4 hours Bradycardia
Esmolol 80 mg bolus over 30 secs
then
150 mg/kg/min IV infusion
1–2 min 10-20 min Bradycardia
Parenteral medications used for treatment of hypertensive crisis
49
50. Drug Dose Onset of Action Duration Adverse effects Pearls
Diltiazem
Inj. Dilzem
25mg/5ml)
Bolus 0.25 mg/ kg
Infusion – 5-20 mg/ h
1-3 min 1-3 hours Bradycardia Initial bolus
recommended
Verapamil
(Inj. Clovera
5mb/2ml)
Bolus 0.075 mg/ kg- 0.15 3-5 min 0.5 – 6 hours Bradycardia
Nicardipine
NA
2.5 -15 mg/ h 5-15 min 4- 6 hours Tachycardia
Clevidipine
NA
Continuous infusion – 1-
21mg/h
2-4 min 5 – 15 min Bradycardia
Parenteral medications used for treatment of hypertensive crisis
50
51. Special indications and warnings for parenteral medications
Drug Special Indications Warnings
Nitroglycerin
Inj. NIG 25/50 mg
Most hypertensive
emergencies,
coronary ischemia
Headache; can develop tolerance, tachycardia, vomiting,
methemoglobinemia, flushing
Sodium
Nitroprusside
Inj. Nipress 50 mg
Most hypertensive
emergencies
Can develop cyanide toxicity,
acidosis, methemoglobinemia, increased intracranial
pressure, nausea, vomiting, muscle twitching
Labetalol
Inj. Lobet 5/10/20/100 mg
Most hypertensive
emergencies,
aortic dissection
Avoid in acute heart failure, bradycardia, and
Broncho constrictive disease
Esmolol
Inj. Esmocard 100 mg
Aortic dissection Avoid in acute heart failure, broncho constrictive disease, and
heart block
Hydralazine
Inj. Hydralaze 25 mg
Eclampsia reflex tachycardia, headache
Phentolamine
Inj. Fentanor 10 mg
Catecholamine excess Flushing, headache, tachycardia
Enalaprilat
NA
Acute left ventricular
failure
Avoid in acute myocardial ischemia
51
53. Labetalol
• Combined alpha and beta blocker
• Dose: 10–80 mg IV bolus every 10 minutes to a
maximum dose of 300 mg
• Infusion: 0.5–2 mg/min
• Onset/duration of action: 5–10 minutes/ 3–6 hours
• Adverse effects- Bradycardia, bronchospasm
• Avoid in congestive heart failure (CHF), bronchial
asthma
53
Does not reduce
the
Cardiac Output
54. Metoprolol
• Selective β-1 blocker
• Dose: 5 mg repeat up to total dose of 15 mg
• Onset duration: 5 min/ 8 hours
• Adverse effects: Bradycardia, Hypotension
54
Inj. Betaloc 1 mg/ ml – 5 ml
55. Esmolol
• Short acting cardioselective beta- blocker
• Dose: 500 mcg/Kg IV bolus can be repeated after 5 minutes
• Infusion: 50–300 mcg/Kg/min
• Onset/duration of action after discontinuation: 1–5
minutes/15–30 minutes
• Avoid in patients with heart block, CHF, asthma
• May precipitate Bradycardia, CHF, heart block, bronchospasm
55
Inj. Cardesmo
Inj. Esmocard
Inj. Miniblock
Inj. Neotack
57. Nicardipine
• Second-generation dihydropyridine calcium-channel blocker
• high vascular selectivity and strong cerebral and coronary
vasodilatory activity
• Dose 5 -15 mg/h
• Onset/ duration of action: 5-15 min/ within 30 min
• Increase both stroke volume and coronary blood flow with a
favorable effect on myocardial oxygen balance
• Can be used in coronary artery disease & systolic heart failure
57
Not
Available
in India
58. Clevidipine
• Third-generation dihydropyridine calcium-channel
blocker. Stroke volume and cardiac output usually
increase by reducing the peripheral vascular resistance
• Dose: 1–2 mg/ hour can be increased
• Onset/ offset of action: 1 min/ metabolized by plasma
esterases
• Clevidipine is insoluble in water and formulated as a
20% phospholipid emulsion for injection
• Lipid overload if used in large quantity
58
Not
Available
in India
59. Diltiazem
• Non-dihydropyridine calcium channel blocker
• Oral dose: 60 -120 mg BD maximum 360 mg in
two divided dose
• IV: 0.25 mg/kg bolus repeated if needed then
infusion of 5-10 mg per hour
• Slow infusion must me continuously monitored –
can precipitate heart block in sensitive individuals
59
Tab Dilzem 30/60/120
SR 90
Inj. Dilzem 25mg
60. Verapamil
• Non-dihydropyridine calcium channel blocker
• Oral dose 80 mg TDS maximum 480 mg per day in
divided doses
• IV 5-10 mg slow IV under monitoring
• Can be repeated after 30 minutes -if inadequate
response then take up oral maintenance
60
Tab Calaptin 40/80
Inj. Calaptin 5 mg
62. Nitroglycerine
• Nitrates produce NO and activates cGMP and relaxation of
vascular smooth muscles
• Dose: 5–100 mcg/min IV infusion
• Onset/duration of action: 2–5 minutes/ 5–15 minutes
• Mostly venodilator with modest arterial dilation
• Tolerance, Headache, tachycardia, flushing, vomiting,
Methemoglobinemia
62
Tab Nitrocontin 2.6 mg
Inj. NG-Care 25 mg/ 5 ml
63. Fenoldopam
• Selective D1 receptor partial agonist vasodilation
of most arterial beds, including renal, mesenteric,
and coronary arteries
• Onset/ Duration: 4 minutes/ < 10 minutes
• Linear dose–response relationship at usual
clinical doses
• Dose: 0.05 -0.3 mcg/kg/min
63
Begin simultaneous oral medicines
By Baxter
Available
64. Phentolamine
• Pure α-blockade
• Reflex tachycardia, orthostatic hypotension
• Dose: 5–15 mg IV bolus, repeat every 5–15 minutes
• Infusion: 0.2–5 mg/min
• Onset/duration of action after discontinuation: 1–2
mins/ 10–30 mins
• Used in syndromes with excess catecholamine
(pheochromocytoma)
64
65. Sodium Nitroprusside
• It is both arterial and venous dilator and works on both the resistance
and capacitance vessels with rapid onset and offset of action
• Dose: 0.25–10 mcg/Kg/min IV infusion
• Onset/ duration of action after discontinuation: Seconds/ 2–3 minutes
• Historically used for most hypertensive emergencies
• Dose can be titrated to a target BP
• Infusion bag, and delivery set must be light-resistant or covered
• Nausea, vomiting, muscle twitching on prolonged use (>24–48 hours)
• Thiocyanate/cyanide intoxication, metabolic acidosis in patients with
renal impairment
• Thiocyanate level >10 mg/dL should be avoided
65
Drug to be avoided
Marik PE, Varon J. Hypertensive crises: challenges and management.
Chest 2007; 131:1949–1962
66. Hydralazine
• Acts directly on the arterial bed – reduce diastolic pressure more
than systolic and cause reflex tachycardia – angina may be
precipitated due to increased cardiac work and steal
phenomenon
• Dose: 10–20 mg IV bolus may be repeated every 30 minutes till
goal BP is reached or unacceptable tachycardia develops
• Onset/duration of action: 10–30 mins/2–4 hours
• Avoid in patients with increased ICP, ischemic heart disease, and
aortic dissection without concomitant β- blockade
66
Drug to be avoided
68. Acute Pulmonary Edema
Systolic Dysfunction
• Nitroglycerin
• Loop diuretic
Diastolic Dysfunction
• Esmolol, Metoprolol,
labetalol or verapamil in
combination
• Low dose-Nitroglycerin
and
• Low dose-Loop diuretic
68
69. Acute Coronary Syndrome
Preferred medications- Beta-blockers (Labetalol or Esmolol) with a
Vasodilator (Nitroglycerin)
Treat if SBP >160 mmHg and/or DBP>100mm Hg
Reduce BP by 20-30% of baseline
Thrombolytics are contraindicated if BP is >185/100 mm Hg
• The drugs of choice are intravenous nitroglycerin, -blockers, and
angiotensin-converting enzyme (ACE) inhibitors
69
70. Hypertensive encephalopathy
Goal is to reduce MAP by 20% over next 8 hours
Labetalol or Clevidipine are drugs of choice
Avoid Drugs with adverse effects on the central nervous
system agents such as clonidine, reserpine, and methyldopa
Avoid Nitroprusside (used in past) is a powerful arteriolar
dilator, so a rise in ICP may occur
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71. Intracerebral hemorrhage
Labetalol, Esmolol, Nicardipine are agents of choice
Avoid Nitroprusside, Hydralazine
Raised ICP, maintain MAP just below 130 mm Hg (or SBP
<180 mm Hg) for first 24 hours
No raised ICP, maintain MAP <110 mm Hg (or SBP <160
mm Hg) for first 24 hours
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72. Subarachnoid Hemorrhage
– Nicardipine, Labetalol, Esmolol are agents of choice
– Avoid Nitroprusside, Hydralazine
– Maintain SBP <160 mm Hg until the aneurysm is treated or
cerebral vasospasm occurs
– Oral Nimodipine is used to prevent delayed ischemic
neurological deficits, but it is NOT indicated for treating acute
hypertension
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73. Acute ischemic stroke
Labetalol, Nicardipine, Clevidipine -agents of choice
High BP can cause hemorrhagic transformation of infarct,
cerebral edema
But, if CPP is low, ischemic penumbra may occur
Intervene if SBP > 220 or DBP > 120 or MAP > 145 mmHg
(unless associated with end-organ damage is due to high BP)
For thrombolysis, BP < 185/110
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75. Acute Aortic Dissection
Combination of a beta blocker with a vasodilator to reduce
the force of ventricular contraction
Labetalol/ Esmolol with Nitroglycerine
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76. Pregnancy-induced hypertension
Preeclampsia, eclampsia, HELLP (hemolysis, elevated liver
enzyme, low platelet) syndrome
Posterior reversible encephalopathy syndrome (PRES) is a
specific hypertensive emergency during pregnancy
It is characterized by headache, confusion, seizures, and
visual loss
It occurs predominantly due to accelerated hypertension
and eclampsia
76
77. Pregnancy Induced Hypertension
• Use Hydralazine, Labetalol, Nifedipine
• Avoid Nitroprusside, ACE inhibitors, Esmolol
• SBP <160 mm Hg and DBP <110 mm Hg
• Platelet count < 100,000 cells mm3 BP should be maintained below
150/100 mm Hg.
• IV magnesium sulfate to avoid seizures
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78. Renal emergencies
Pathophysiology includes a variety of mechanisms, such as
increased vascular resistance, activation of the renin-angiotensin-
aldosterone axis and hyperparathyroidism
Goal is to prevent further renal damage by maintaining adequate
blood flow
Sodium Nitroprusside and labetalol are useful
Short-term dialysis is sometimes necessary
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79. Adrenergic Crises
Achieving adequate α-blockade
• Prazosin 2.5/ 5 mg BD or TDS maximum 20 mg
• Doxazosin 1/ 2 mg OD maximum 16 mg
• Terazosin 1/2/5 mg OD
β-blockers
• Propranolol 10 mg QID
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80. Acute Postoperative Hypertension
Adequate control of blood pressure during OT
• Reduce Surgical stimulation
• Avoid fluids overload
Analgesics
• Opioids
• Non-opioids
Beta Blockers- Esmolol, or Labetalol
CCB- Nicardipine, Clevidipine
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81. Continue outpatient management to normal
BP. Identify and treat causes of secondary
hypertension.
Oral therapy to decrease
mean arterial BP 25% in 24 hr
Initiate oral therapy to maintain
stable BP
Hypertensive
urgency
Consider inpatient vs.
outpatient therapy based on
patient’s clinical picture and
reliability
Parenteral therapy to decrease mean
arterial BP by up to 25% in 2 hr or unit
organ damage satbilized
No acute
organ damage
Measure
BP
Systolic >180 mmHg or
Diastolic > 120 mmHg
Systolic <180 mmHg or
Diastolic < 120 mmHg
Acute or ongoing
organ injury
No acute
organ damage
Hypertensive
emergency;
Admit to intensive
care unit
Outpatient treatment with oral
therapy and nonpharmacologic
interventions
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82. MCQ No. 5
Which of the Drugs is available in India??
1. Enalaprilat
2. Nicardipine
3. Clevidipine
4. None of the above
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