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Hypertension and
Hypotension in the
Emergency Department
Hypertension
How do we manage
Hypertension in the
ER??
Hypertension
Management in the ED
First Step:
Categorize Types of
Hypertension
Four Categories of
Hypertension
- Hypertensive Emergency
- Hypertensive Urgency
- Acute Hypertensive Episode
- Transient Hypertension
What is a
Hypertensive
Emergency?
Hypertensive
Emergency
- A relative increase in blood pressure
from baseline combined with Target
Organ Dysfunction (TOD)
- No Defined Pressure Measurement
- Target Organ Damage is evident
- Also known as Hypertensive Crisis or
Malignant Hypertension
- The MOST Serious form of hypertension
How do we define
Target Organ
Dysfunction
???
Target Organ
Dysfunction
Evidence of Damage or
Injury to Target Organs
such as the Heart, Brain,
Lungs, Kidneys, or Aorta.
Examples of Target
Organ Dysfunction
How do we determine if
Target Organ Dysfunction
is present?
2.
3.
UA or urine dip: (looking for proteinuria, red cells, or red cell casts)
4.
5.
6.
7.
Diagnosis and
Management
of
Hypertensive
Emergency
Hypertensive
Encephalopathy
Pathophysiology:
- Loss of Cerebral Autoregulation of blood flow
resulting in hyperperfusion of the brain, loss
of integrity of the blood brain barrier, and
vascular necrosis.
- Loss of Autoregulation occurs at a constant
cerebral blood flow of above MAP 150 to 160
mmHg.
- Acute Onset
- Reversible
Hypertensive
Encephalopathy
Symptoms:
Headache, Nausea/Vomiting, Lethargy,
Confusion, Lateralizing neurological symptoms
that are not often in an anatomical distribution.
Signs:
Papilledema, Retinal Hemorrhages
Decreased level of consciousness, Coma
Focal neurological findings
Management of
Hypertensive
Encephalopathy
Management of
Hypertensive
Encephalopathy
- Nitroprusside is the agent of
choice (T.397) and (R.1759)
- Nitroglycerin and Labetalol have
been used successfully, but
have not replaced Nitroprusside
Management of
Ischemic
CVA
Ischemic CVA
Pathophysiology:
Elevated Blood Pressure can be the
cause of the central nervous
system event, OR, it may be a
normal physiologic response
(Cushings Reflex)
Ischemic CVA
Management
Ischemic CVA
Management
Management: VERY CONTROVERSIAL!
Recent Trends leans towards NOT
treating hypertension in the presence
of a Cerebrovascular Accident
(thrombotic or embolic) unless
Diastolic Blood Pressure exceeds
140mmHg.
Ischemic CVA
Management
Tintinelli: Favors lowering MAP
(mean arterial pressure) by 20%.
Recommends IV Labetalol in small
doses of 5mg increments IF
Diastolic Blood Pressure is higher
than 140 mmHg.
(T. 398)
Ischemic CVA
Managment
Rosen: In most cases, recommends
no treatment of Hypertension in CVA
patients.
(p. 1760).
- However, the author does
recommend treating HTN if diastolic
blood pressure is greater than 140
mmHg.
Management of
Hemorrhagic CVA
Causes of Hemorrhagic
CVA
Hypertensive
Vascular Disease
Arteriovenous Anomalies (AVM)
Arterial Aneurysms
Tumors
Trauma
Hemorrhagic CVA
Management
Hypertension
associated
with hemorrhagic stroke is
usually transitory and the
result of increased
intracranial pressure and
irritation of the Autonomic
Nervous System
Hemorrhagic CVA
Management
Management of
CHF/
Pulmonary Edema
Congestive Heart
Failure / Pulmonary
Edema
Pathophysiology:
CHF / Pulmonary
Edema
Symptoms:
Shortness of Breath, Cough, Chest Pain
Lower Extremity Swelling
Signs:
Jugular Venous Distension, Rales, S3
Gallop
Hepatomegaly, Pedal Edema
CHF / Pulmonary
Edema Management in
the ED
-
Management of
Acute
Coronary Syndrome/
Acute MI
Acute Coronary
Syndrome /
Acute MI
Pathophysiology:
- Increased afterload,
cardiac
workload, and
myocardial oxygen demand
- Decreased coronary
artery blood flow
Acute Coronary
Syndrome /
Acute
Symptoms: MI
Signs:
Congestive Heart Failure Signs,
S4 Gallop
(due to decreased ventricular compliance)
Few physical findings in many patients
Clinical History is very Important
Acute Coronary
Syndrome/
Acute MI
-
Acute Coronary
Syndrome /
Acute MI
Management:
Nitroglycerin IV or Sublingual (T. 398)
Nitroprusside (T. 398)
Beta Blockers (Esmolol,Lopressor) (T.
356-357)
Nitroglycerin is Drug of Choice (R.
1761)
Dissection of
Thoracic Aorta
Dissection of Thoracic
Aorta
Pathophysiology:
- Atherosclerotic Vascular Disease,
Chronic Hypertension, increased
shearing force on the thoracic aorta,
leading to intimal tear.
- 50% begin in ascending aorta
- 30% at aortic arch
- 20% in descending aorta (R.1762-3)
Dissection of Thoracic
Aorta
Symptoms:
-
Signs:
Dissection of Thoracic
Aorta
Management:
-
Dissection of Thoracic
Aorta
Optimal Blood Pressure in these
patients is undefined and
must be tailored for each
patient, however,
SBP of 120-130mmHg may be a
intial starting point. (T.408)
Acute Renal
Failure
Hypertensive Glomerulonephropathy,
Acute Tubular Necrosis (ATN)
Signs:
-
Pheochromocyto
ma
Pheochromocytoma
Pathophysiology:
- Alpha and Beta stimulation of the
cardiovascular system due to
adrenergic excess states
Pheochromocytoma
Symptoms:
Episodic Headaches, flushing, tremor,
diaphoresis, diarrhea, hyperactivity,
and palpitations
Signs:
Tachycardia, tachypnea, tremor,
hyperdynamic state (high output CHF)
Pheochromocytoma
Management:
-
Toxemia of Pregnancy
Eclampsia/PreEclampsia
Toxemia of Pregnancy
Pathophysiology:
-
Toxemia of Pregnancy
Symptoms:
Lower extremity swelling, headache,
confusion, seizures, coma
Signs:
Edema, hyperreflexia, elevation of blood
pressure related to baseline BP prior to
pregnancy (elevation may be mild
125/75)
Toxemia of Pregnancy
Management:
-
Summary of Medications
used for Hypertensive
Emergencies
- Intravenous Nitroglycerin:
Start at 0.2 to 0.4 mcg/kg/min (10 to 30 mcg/min) and
rapidly increase in 5 to10 mcg/min increments. Titrate to BP
and symptomatic improvement. (T.369)
- Nitroprusside:
Start 0.3 mcg/kg/min and titrate up every 5 to 10 minutes
based on BP and clinical response. (T.369)
- Esmolol: 500 mcg/kg initial bolus over 1 minute, then start
infusion at 50 to 150 mcg/kg/min (T.408)
- Metoprolol (Lopressor): 5mg IV every 2 minutes for a total of
3 doses, then start infusion at 2 to 5 mg/hr. (T.408)
Summary of Medications
used for Hypertensive
Emergencies
- Labetalol: 20mg IV initial dose, with repeat doses of
40mg to 80mg every 10 minutes to reach desired
effect or max dose 300mg. (T. 408)
-
Hydralazine: 10 to 20mg IV
What is a
Hypertensive
Urgency??
Hypertensive
Urgency
- A relative increase in blood
Hypertensive Urgency
-
What is an Acute
Hypertensive Episode?
Acute Hypertensive
Episode
Elevation of Blood Pressure
relative to baseline, but
WITHOUT evidence of acute OR
impending Target Organ
Dysfunction (TOD)
Management of Acute
Hypertensive Episode
-
What is Transient
Hypertension??
Treatment of Transient
Hypertension
-
SWITCHING
GEARS
Hypotension/Shock
Management in the ED
Hypotension/Shock
Types of Shock:
- Hypovolemic
(inadequate circulating volume)
- Cardiogenic
(inadequate pump function)
- Distributive
(peripheral vasodilitation)
- Obstructive
(extra-cardiac obstruction of blood
flow)
Hypotension/Shock
Goals of Management
1. Determine Cause:
- Usually very apparent
- Can be subtle
- No single Vital Sign that is
diagnostic of
Shock
- Initial Therapy guided by clinical
findings
Management of
Hypotension/Shock
Hypotension/Shock
Goals of Resuscitation
ABCs:
A- Secure Airway (intubate if needed)
B- Insure oxygenation and ventillation
C- Provide Hemodynamic
Stabilization (correction of
hypotension based on etiology)
Resuscitation
Initiate Fluid Therapy:
0.25 to 0.5 Liters of Normal
Saline (NS) or similar
isotonic crystalloid should
be administered every 5 to
10 minutes as needed for
correction of hypotension
Rapid Fluid
Administration
It is not unusual for a
patient to require 4 to 6
Liters of fluid in the initial
phase of resuscitation.
Goal of Fluid
Resusciation
-
Inotropic Support
If NO response to initial fluid
infusion of 3 to 4 L is noted, OR if
there are signs of fluid overload
(pulmonary edema), Inotropic
agents should be started.
Inotropic Agents
-
Inotropic Agents
-
Inotropic Agents
-
End Point of
Resuscitation
-
Questions ???