Hypertensive emergency

Diagnosis

End-organ damage 2/2 increased BP (generally >180/120, usually > 220/130)
Brain - Encephelopathy, seizure, ICH, ischemic stroke
Eyes - Retinal hemorrhage, exudate, papilledema
CV - MI, CHF/LV failure/pulm edema, aortic dissection
Renal - Acute failure, hematuria, proteinuria
Ancillary Tests
Chemistry - assess renal failure
UA - Assess renal failure, glomerulo nephritis, preeclampsia
Troponin
CXR - Evidenceo failure, dissection
ECG

Etiology

Idiopathic
Sympathomimetic drug use
Preeclampsia
Acute glomerulonephritis

Treatment

Goal: Lower diastolic pressure to 105mmHg within 2-6 hours
Maximum initial fall in BP should not exceed 25% of presenting value
Be careful of lowering BP in pts with CVA!

Drug Dose Mechanism Pros Cons Notes Nitroprusside 0.25-8µg/kg/min

(start at 0.25)

Arterial and veno-dilator 1. Very effective

2. Immediate onset/offset

1. Cyanide Toxicity

2. Coronary steal?

3. Incr HR

1. Avoid in liver/renal failure

2. Avoid with incr ICP

3. Avoid in pregnancy

Nitgroglycerin 5-100 µg/min Veno>arteriodilation 1. Rapid on/offset

2. Increases coronary flow

Causes Tachycardia Drug of choice in pts w/ cardiac ischemia,

LV dysfunction, and pulm edema

Labetalol 20-80mg IV bolus q10min OR

0.5-2mg/min IV

Beta>alpha blocker 1. No change in HR, cerebral flow

2. Rapid onset

Avoid in COPD, CHF

heart block

1. Consider in ACS

2. Consider in ischemic CVA

Esmolol 250-500 µg/kg/min;

may repeat bolus after

5min or incr to 300µg/min

Beta selective 1. Rapid on/offset Avoid in COPD, CHF

bradycardia

Consider in ACS

Nicardipine 5-15mg/h Decreases PVR Good for intracranial pathology Slower onset/offset Avoid in CHF, ACS Hydralazine 5-10mg IV bolus, max dose 20mg OR 0.5-1mg/min IV infusion Arteriolar vasodilator Rarely causes hypotension Avoid in CAD Primarily used in pregancy Phentolamine 5-10mg IV bolus q5-15min OR

0.2-5mg/min IV infusion

Alpha blocker Used for catecholamine-induced HTN Enalapril 1.25mg over 5min q6hr Decreases HR, SV, systemic arterial pressure Does not impair cerebral flow Variable response 1. Used in pts at risk for cerebral hypotension, CHF

2. Avoid in pregnancy

Disease Specific

HTN Encephalopathy

    Controlled redxn of BP over 1h; never < 110 diastolic

         Labetolol, nicardipine, fenoldopam; nitroprusside of diastolic > 140

Stroke

    10-15% reduction of MAP; diastolic not < 110

    lower to 185/110 in ischemic stroke to meet t-PA criteria

         Labetolol, nicardipine, nitroprusside as above

Acute Aortic Dissection

    Rapid redxn of BP, systolic bp 100-120; HR 60-80 within 20mins

    Prevent reflex tachycardia

         Nitroprusside, fenoldopam, nicardipine with metoprolol or esmolol; labetolol alone

ACS and Pulmonary Edema

    Nitroglycerin

Eslampsia/Pre-eclampsia

    Labetolol, nicardipine or IV hydralazine

    Magnesium

Cocaine and Amphetamine Toxicitiy

    BDZs

    Mixed alpha + B blockade: phentolamine or nitroprusside plus beta blocker

Pheochromocytoma

    Phentolamine or nitroprusside plus beta blocker

ARF

    Fenoldopam, nicardipine; nitroprusside risk cyanide toxicity (renal metabolism)

Source

Adapted from Bessen, Bresler (ACEP '09), UpToDate

Authors: