Hypertensive emergency: Difference between revisions
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*Chem 8 - assess renal failure and possible secondary causes | *Chem 8 - assess renal failure and possible secondary causes | ||
*Cardiac enzymes | *Cardiac enzymes | ||
* | *[[Urinalysis]] - Assess renal failure, glomerulonephritis, preeclampsia | ||
*Chest Xray - evaluate for pulmonary edema or dissection | *Chest Xray - evaluate for pulmonary edema or dissection | ||
*[[ECG]] - LVH, ischemia | *[[ECG]] - LVH, ischemia |
Revision as of 18:02, 2 October 2016
High blood pressure without symptoms is NOT hypertensive emergency (see asymptomatic hypertension)
Background
- End-organ damage due to increased BP (generally >180/120, usually > 220/130, but note that absolute BP is not as important as presence of end-organ damage)
Etiology
- Idiopathic
- Sympathomimetic drug use
- Preeclampsia
- Acute glomerulonephritis
Prehospital
- Prehospital BP measurements should be considered reliable[1]
- Acute lowering of BP is not typically recommended
- Focus on ABCs (assess need for Intubation or respiratory support)
- Provide care of treatable etiologies
- CHF
- Respiratory Failure from Pulmonary Edema
- Acute Pain
Clinical Features
End-Organ Dysfunction[2]
- Brain - Hypertensive encephalopathy, seizure, ICH, ischemic stroke
- Eyes - Retinal hemorrhage, papilledema
- Heart - ACS, CHF/LV failure/pulmonary edema
- Vascular - Dissection, Microangiopathic hemolytic anemia
- Renal - Acute failure, hematuria, proteinuria, Glomerulonephritis
- OBGYN - Eclampsia
Differential Diagnosis
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Evaluation
Consider any of the following based on the patient's clinical presentation[3]
- CBC - assess for hemolytic anemia
- Chem 8 - assess renal failure and possible secondary causes
- Cardiac enzymes
- Urinalysis - Assess renal failure, glomerulonephritis, preeclampsia
- Chest Xray - evaluate for pulmonary edema or dissection
- ECG - LVH, ischemia
Treatment
- Goal: Lower diastolic pressure to 105 mmHg within 2-6 hours
- Maximum initial fall in BP should not exceed 25% of presenting value in 1st hour
- Be careful of lowering BP in patients with CVA
By Drug
Drug | Dose | Mechanism | Pros | Cons | Notes |
Nitroprusside |
0.3-0.5 mcg/kg/min IV initial infusion Incr by 0.5mcg/kg/min up to 2mcg/kg/min
|
Arterial > 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 increased ICP 3. Avoid in pregnancy |
Nitroglycerin | Start 5-100 mcg/min | Veno>arteriodilation |
1. Rapid on/offset 2. Increases coronary flow |
Causes Tachycardia |
Drug of choice in patients with cardiac ischemia, LV dysfunction, or pulmonary edema |
Labetalol |
20-80mg IV bolus q10min OR 0.5-2mg/min IV infusion or 200mg to 400mg PO BID |
Beta>alpha blocker |
1. No change in HR, cerebral flow 2. Rapid onset |
Avoid in COPD, CHF and heart block |
1. Consider in ACS 2. Consider in ischemic CVA |
Esmolol |
Load 250-500 mg/kg/ over 2min Infuse 50mcg/kg/min over 4min - if ineffective repeat load, increase infusion rate by 50mcg/kg/min up to 200mcg/kg/min |
Beta selective | Rapid on/offset |
Avoid in COPD, CHF bradycardia |
Consider in ACS |
Nicardipine |
Start 5mg/h If ineffective after 15min increased in 2.5mg/hr interval up to 15mg/hr |
Decreases PVR |
Good for intracranial pathology | Slower onset/offset | Avoid in CHF, ACS |
Phentolamine |
5-10mg IV bolus q5-15min OR 0.2-5mg/min IV infusion |
Alpha blocker | Used for catecholamine-induced hypertension | ||
Enalaprilat | Bolus 1.25mg over 5min q6hr, titrate at 30min intervals to max of 5mg q6hr | Decreases HR, SV, systemic arterial pressure | Does not impair cerebral flow | Variable response |
1. Used in patients at risk for cerebral hypotension, CHF 2. Avoid in pregnancy |
By Disease
Aortic Dissection
- Rapidly reduce sys BP to 100-120; HR 60-80 within 20min
- Avoid volume depletion
- Prevent reflex tachycardia
- Labetolol alone
- Nitroprusside or nicardipine AFTER metoprolol or esmolol
Pulmonary Edema
- Reduce BP by 20-30%
- Promote diuresis AFTER vasodilation
ACS
- No more than 20-30% reduction for SBP >160
- Consider NTG, beta-blocker
Cocaine/Amphetamine Toxicitiy
- Benzos
- Mixed alpha + B blockade
- Phentolamine OR nitroprusside AND beta blocker
Renal Failure
- Reduce BP by no more than 20%
- Avoid nitroprusside (renal metabolism)
- Labetalol or nicardipine
Eclampsia/Pre-eclampsia
- Goal BP <160/110
- Labetalol or nicardipine
- Magnesium
Encephalopathy
- Decrease MAP by 15-20%
- Avoid overly aggressive lowering
- Nicardipine or labetalol
CVA
- SAH
- ICH
- See current guidelines for best practice
- Labetalol or Nicardipine or Esmolol
- Ischemic
- If thrombolytic treatment is planned then goal systolic blood pressure 185 mm Hg[4]
- If no thrombolytics then consider blood pressure control if SBP >220 mmHg or DBP >120 mmgHg
- Labetalol or Nicardipine are both effective and safe
Pheochromocytoma
- Phentolamine OR (nitroprusside AND beta blocker)
See Also
Video
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References
- ↑ Cienki JJ, DeLuca LA. Agreement between emergency medical services and expert blood pressure measurements. J. Emerg Med. 2012;43(1):64-68.
- ↑ Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.
- ↑ 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens. 2013;31(10):1925-1938.
- ↑ Acute Stroke Practice Guidelines for Inpatient Management of Ischemic Stroke and Transient Ischemic Attack (TIA) https://www.heart.org/idc/groups/heart-public/@wcm/@private/@hcm/documents/downloadable/ucm_309996.pdf