Hypertensive emergency: Difference between revisions
(25 intermediate revisions by 8 users not shown) | |||
Line 7: | Line 7: | ||
===Etiology=== | ===Etiology=== | ||
*Idiopathic | *Idiopathic | ||
*Sympathomimetic drug use | *[[Sympathomimetic]] drug use | ||
*Preeclampsia | *[[Preeclampsia]] | ||
*Acute glomerulonephritis | *Acute [[glomerulonephritis]] | ||
===Prehospital=== | ===Prehospital=== | ||
*Prehospital BP measurements should be considered reliable<ref>Cienki JJ, DeLuca LA. Agreement between emergency medical services and expert blood pressure measurements. J. Emerg Med. 2012;43(1):64-68.</ref> | *Prehospital BP measurements should be considered reliable<ref>Cienki JJ, DeLuca LA. Agreement between emergency medical services and expert blood pressure measurements. J. Emerg Med. 2012;43(1):64-68.</ref> | ||
*Acute lowering of BP is not typically recommended | *Acute lowering of BP is not typically recommended | ||
*Focus on ABCs (assess need for [[ | *Focus on ABCs (assess need for [[intubation]] or [[BiPAP|respiratory support]]) | ||
*Provide care of treatable etiologies | *Provide care of treatable etiologies | ||
**[[CHF]] | **[[CHF]] | ||
**Respiratory | **[[Respiratory failure]] from [[pulmonary edema]] | ||
**Acute | **Acute pain | ||
==Clinical Features== | ==Clinical Features== | ||
'''End-Organ Dysfunction<ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>''' | '''End-Organ Dysfunction<ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>''' | ||
* | *Acute kidney injury | ||
* | **Often with microscopic hematuria | ||
* | *Pulmonary edema | ||
* | *Type-II myocardial infarction | ||
* | *Hypertensive encephalopathy | ||
* | **Visual disturbances | ||
**Seizure | |||
**Delirium | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Line 33: | Line 35: | ||
==Evaluation== | ==Evaluation== | ||
===Workup=== | |||
''Consider any of the following based on the patient's clinical presentation''<ref>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.</ref> | ''Consider any of the following based on the patient's clinical presentation''<ref>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.</ref> | ||
*CBC - assess for hemolytic anemia | *CBC with peripheral smear- assess for microangiopathic hemolytic anemia | ||
*Chem 8 - assess renal failure and possible secondary causes | *Chem 8 - assess renal failure and possible secondary causes | ||
*Cardiac enzymes | *[[Troponin|Cardiac enzymes]] | ||
*[[Urinalysis]] - Assess renal failure, glomerulonephritis, preeclampsia | *[[Urinalysis]] - Assess renal failure, glomerulonephritis, preeclampsia | ||
* | *[[CXR]] - evaluate for pulmonary edema or dissection | ||
*[[ECG]] - LVH, ischemia | *[[ECG]] - [[LVH]], [[myocardial ischemia|ischemia]] | ||
*[[CT head]] - in hypertensive encephalopathy, may not show acute hemorrhage or other acute pathology | |||
**Hypertensive encephalopathy is thought to be secondary to alteration in cerebral auto-regulation leading to [[posterior reversible encephalopathy syndrome]] (now called reversible posterior leukoencephalopathy). Most patients will show changes on MRI, although this is not necessarily indicated in the emergency department. | |||
== | ===Diagnosis=== | ||
*Goal: Lower diastolic pressure to | *Must have evidence of end-organ dysfunction | ||
**''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])'' | |||
**''Symptoms such as headache,epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction'' | |||
==Management== | |||
*Goal: Lower diastolic pressure to 100 mmHg within 2-6 hours | |||
**Maximum initial fall in BP should not exceed 25% of presenting value in 1st hour | **Maximum initial fall in BP should not exceed 25% of presenting value in 1st hour | ||
*Be careful of lowering BP in patients with [[CVA]] | *Be careful of lowering BP in patients with [[CVA]] | ||
Line 61: | Line 71: | ||
0.3-0.5 mcg/kg/min IV initial infusion | 0.3-0.5 mcg/kg/min IV initial infusion | ||
Increase by 0.5 mcg/kg/min up to 2mcg/kg/min | |||
| Arterial > | | Arterial > venodilator | ||
| | | | ||
1. Very effective | 1. Very effective | ||
Line 75: | Line 85: | ||
2. Coronary steal? | 2. Coronary steal? | ||
3. | 3. Increased HR | ||
| | | | ||
Line 93: | Line 103: | ||
2. Increases coronary flow | 2. Increases coronary flow | ||
| Causes | | Causes tachycardia | ||
| | | | ||
Drug of choice in patients with cardiac ischemia, | Drug of choice in patients with cardiac ischemia, | ||
Line 102: | Line 112: | ||
| [[Labetalol]] | | [[Labetalol]] | ||
| | | | ||
20-80mg IV bolus | 20-80mg IV bolus q10 min '''OR''' | ||
0.5- | 0.5-2 mg/min IV infusion or | ||
200mg to 400mg PO BID | 200mg to 400mg PO BID | ||
| Beta> | | Beta>α-blocker | ||
| | | | ||
1. No change in HR, cerebral flow | 1. No change in HR, cerebral flow | ||
Line 123: | Line 133: | ||
| [[Esmolol]] | | [[Esmolol]] | ||
| | | | ||
Load 250-500 | Load 250-500 mcg/kg over 2min | ||
Infuse | Infuse 50 mcg/kg/min over 4min | ||
- if ineffective repeat load, increase infusion rate by 50mcg/kg/min up to | - if ineffective repeat load, increase infusion rate by 50mcg/kg/min up to 300mcg/kg/min | ||
| Beta selective | | Beta selective | ||
Line 153: | Line 163: | ||
| [[Phentolamine]] | | [[Phentolamine]] | ||
| | | | ||
5- | 5-15mg IV bolus q5-15min '''OR''' | ||
0.2-5mg/min IV infusion | 0.2-0.5mg/min IV infusion | ||
| | | α-blocker | ||
| | | | ||
| | | | ||
Line 171: | Line 181: | ||
2. Avoid in pregnancy | 2. Avoid in pregnancy | ||
|- | |||
| [[Clonidine]] | |||
| | |||
0.1 - 0.3 mg PO q12 scheduled; For hypertensive emergency, 0.2 mg x1, then 0.1 mg q1 hr PRN, max 0.6 mg total | |||
| α-2 agonist, BP effects within 30-60 min after PO dose | |||
| | |||
| | |||
| Reduced CNS sympathetic flow, decreasing SVR, HR, BP; no renal blood flow changes; tolerance/tachyphylaxis develop quickly | |||
|- | |||
| [[Hydralazine]] | |||
| | |||
10 - 20 mg slow IV/IM bolus q4-6 hr PRN, max 40 mg/dose | |||
| Peripheral vasodilator, with fall in BP beginning within 30 min, lasting 2-4 hrs | |||
| | |||
| | |||
| Decrease in DBP > SBP; has increased HR, stroke volume and cardiac outpt; preferential vasodilation > venodilation | |||
|} | |} | ||
Line 181: | Line 213: | ||
*Avoid volume depletion | *Avoid volume depletion | ||
*Prevent reflex tachycardia | *Prevent reflex tachycardia | ||
** | **Labetalol alone | ||
**Nitroprusside or nicardipine AFTER metoprolol or esmolol | **Nitroprusside or nicardipine AFTER metoprolol or esmolol | ||
Line 196: | Line 228: | ||
*[[Benzos]] | *[[Benzos]] | ||
*Mixed | *Mixed α + B blockade | ||
**Phentolamine OR nitroprusside AND | **Phentolamine '''OR''' nitroprusside AND β-blocker | ||
====[[Renal Failure]]==== | ====[[Renal Failure]]==== | ||
Line 211: | Line 243: | ||
*Magnesium | *Magnesium | ||
==== | ====[[Hypertensive emergency]]==== | ||
*Decrease MAP by 15-20% | *Decrease MAP by 15-20% | ||
**Avoid overly aggressive lowering | **Avoid overly aggressive lowering | ||
*Nicardipine or labetalol | *[[Nicardipine]] or [[labetalol]] | ||
====[[CVA]]==== | ====[[CVA]]==== | ||
*SAH | *[[SAH]] | ||
**See [[Subarachnoid Hemorrhage (SAH)]] | **See [[Subarachnoid Hemorrhage (SAH)]] | ||
*[[ICH]] | *[[ICH]] | ||
Line 225: | Line 256: | ||
**[[Labetalol]] or [[Nicardipine]] or [[Esmolol]] | **[[Labetalol]] or [[Nicardipine]] or [[Esmolol]] | ||
*[[Stroke (Main)|Ischemic]] | *[[Stroke (Main)|Ischemic]] | ||
**If thrombolytic treatment is planned then goal systolic blood pressure 185 mm Hg<ref>Acute Stroke Practice Guidelines for Inpatient Management of Ischemic | **If thrombolytic treatment is planned then goal systolic blood pressure 185 mm Hg and diastolic blood pressure 110 mm Hg<ref>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</ref> | Stroke and Transient Ischemic Attack (TIA) https://www.heart.org/idc/groups/heart-public/@wcm/@private/@hcm/documents/downloadable/ucm_309996.pdf</ref> | ||
**If no thrombolytics then consider blood pressure control if SBP >220 mmHg or DBP >120 mmgHg | **If no thrombolytics then consider blood pressure control if SBP >220 mmHg or DBP >120 mmgHg | ||
Line 231: | Line 262: | ||
====[[Pheochromocytoma]]==== | ====[[Pheochromocytoma]]==== | ||
*Phentolamine OR (nitroprusside AND | *Phentolamine '''OR''' (nitroprusside AND β-blocker) | ||
==See Also== | ==See Also== |
Revision as of 00:03, 6 June 2020
High blood pressure without symptoms is NOT hypertensive emergency (see asymptomatic hypertension)
Background
- Definition: end-organ damage due to hypertension
- Blood pressure is generally >180/120 (usually > 220/130), but presence of end-organ damage defines disease (not absolute blood pressure number)
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]
- Acute kidney injury
- Often with microscopic hematuria
- Pulmonary edema
- Type-II myocardial infarction
- Hypertensive encephalopathy
- Visual disturbances
- Seizure
- Delirium
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
Workup
Consider any of the following based on the patient's clinical presentation[3]
- CBC with peripheral smear- assess for microangiopathic hemolytic anemia
- Chem 8 - assess renal failure and possible secondary causes
- Cardiac enzymes
- Urinalysis - Assess renal failure, glomerulonephritis, preeclampsia
- CXR - evaluate for pulmonary edema or dissection
- ECG - LVH, ischemia
- CT head - in hypertensive encephalopathy, may not show acute hemorrhage or other acute pathology
- Hypertensive encephalopathy is thought to be secondary to alteration in cerebral auto-regulation leading to posterior reversible encephalopathy syndrome (now called reversible posterior leukoencephalopathy). Most patients will show changes on MRI, although this is not necessarily indicated in the emergency department.
Diagnosis
- Must have evidence of end-organ dysfunction
- High blood pressure without symptoms is NOT hypertensive emergency (see asymptomatic hypertension)
- Symptoms such as headache,epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction
Management
- Goal: Lower diastolic pressure to 100 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 Increase by 0.5 mcg/kg/min up to 2mcg/kg/min
|
Arterial > venodilator |
1. Very effective 2. Immediate onset/offset |
1. Cyanide Toxicity 2. Coronary steal? 3. Increased 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 q10 min OR 0.5-2 mg/min IV infusion or 200mg to 400mg PO BID |
Beta>α-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 mcg/kg over 2min Infuse 50 mcg/kg/min over 4min - if ineffective repeat load, increase infusion rate by 50mcg/kg/min up to 300mcg/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 |
5-15mg IV bolus q5-15min OR 0.2-0.5mg/min IV infusion |
α-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 |
Clonidine |
0.1 - 0.3 mg PO q12 scheduled; For hypertensive emergency, 0.2 mg x1, then 0.1 mg q1 hr PRN, max 0.6 mg total |
α-2 agonist, BP effects within 30-60 min after PO dose | Reduced CNS sympathetic flow, decreasing SVR, HR, BP; no renal blood flow changes; tolerance/tachyphylaxis develop quickly
| ||
Hydralazine |
10 - 20 mg slow IV/IM bolus q4-6 hr PRN, max 40 mg/dose |
Peripheral vasodilator, with fall in BP beginning within 30 min, lasting 2-4 hrs | Decrease in DBP > SBP; has increased HR, stroke volume and cardiac outpt; preferential vasodilation > venodilation
|
By Disease
Aortic Dissection
- Rapidly reduce sys BP to 100-120; HR 60-80 within 20min
- Avoid volume depletion
- Prevent reflex tachycardia
- Labetalol 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 α + B blockade
- Phentolamine OR nitroprusside AND β-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
Hypertensive emergency
- 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 and diastolic blood pressure 110 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 β-blocker)
See Also
Video
{{#widget:YouTube|id=KknXoRngPQM}}
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