Hypertensive crisis resident survival guide: Difference between revisions
No edit summary |
No edit summary |
||
Line 27: | Line 27: | ||
==Management== | ==Management== | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | A01 | | | | | | |A01=}} | |||
{{familytree | | | | |!| | | | | | | |}} | |||
{{familytree | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br> | {{familytree | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br> | ||
❑ '''CNS:''' severe [[headache]], [[dizziness]], [[confusion]], weakness/numbness, [[dysphagia]], altered level of consciousness<br> ❑ '''Eyes:''' [[pain]], blurred/loss of vision<br> ❑ '''Cardiopulmonary:''' [[chest pain]], [[dyspnea]]<br>❑ '''Renal:''' [[hematuria]], [[proteinuria]], reduced urinary output<br>❑ '''Other:''' [[nausea]], [[vomiting]], [[anxiety]], [[nosebleed]]s | ❑ '''CNS:''' severe [[headache]], [[dizziness]], [[confusion]], weakness/numbness, [[dysphagia]], altered level of consciousness<br> ❑ '''Eyes:''' [[pain]], blurred/loss of vision<br> ❑ '''Cardiopulmonary:''' [[chest pain]], [[dyspnea]]<br>❑ '''Renal:''' [[hematuria]], [[proteinuria]], reduced urinary output<br>❑ '''Other:''' [[nausea]], [[vomiting]], [[anxiety]], [[nosebleed]]s | ||
Line 37: | Line 39: | ||
{{familytree | | | | |!| | | | | |}} | {{familytree | | | | |!| | | | | |}} | ||
{{familytree | | | | C01 | | | |C01=<div style="float: left; text-align: left; width: 40em; padding:1em;">'''Order Labs:'''<br> ❑ [[CBC]]<br> | {{familytree | | | | C01 | | | |C01=<div style="float: left; text-align: left; width: 40em; padding:1em;">'''Order Labs:'''<br> ❑ [[CBC]]<br> | ||
❑ [[Electrolytes]] <br> ❑ [[BUN]] <br> ❑ [[Creatinine]]<br>❑ [[EKG]] (in case of chest pain)<br> ❑ [[CXR]] (in case of chest pain or dyspnea)<br> ❑ | ❑ [[Electrolytes]] <br> ❑ [[BUN]] <br> ❑ [[Creatinine]]<br>❑ [[EKG]] (in case of chest pain)<br> ❑ [[CXR]] (in case of chest pain or dyspnea)<br> ❑ [[CT]] or [[MRI]] (in case of suspicion of aortic dissection) | ||
---- | ---- | ||
<table> | <table> |
Revision as of 20:29, 25 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]; Rim Halaby, M.D. [3]
Overview
Hypertensive crisis is the severe elevation in the blood pressure (systolic blood pressure >179 mm Hg, or diastolic blood pressure >109 mm Hg).[1] Discontinuation of antihypertensive medications is the most common cause of hypertensive crisis.
Classification
Hypertensive crisis is further classified as hypertensive urgency or hypertensive emergency based on either the absence or presence of acute end-organ damage.[2]
Hypertensive Urgency
Hypertensive urgency is the severe elevation in the blood pressure (systolic blood pressure >179 mm Hg, or diastolic blood pressure >109 mm Hg) without any evidence of acute end-organ damage.
Hypertensive Emergency
Hypertensive emergency is the severe elevation in the blood pressure (systolic blood pressure >179 mm Hg, or diastolic blood pressure >109 mm Hg) complicated by acute end-organ dysfunction, such as hypertensive encephalopathy, eclampsia, dissecting aortic aneurysm, acute left ventricular failure with pulmonary edema, acute myocardial infarction, acute renal failure, or symptomatic microangiopathic hemolytic anemia.
Causes
Life Threatening Causes
Hypertensive crisis is a life-threatening condition and must be treated as such irrespective of the cause.
Common Causes
- Antihypertensive medications withdrawal ( beta blockers, clonidine)
- Noncompliance with antihypertensive medications
- Pheochromocytoma
- Side effects of monoamine oxidase inhibitors
- Stimulants (cocaine, methamphetamine, phencyclidine)
Management
Characterize the symptoms: ❑ CNS: severe headache, dizziness, confusion, weakness/numbness, dysphagia, altered level of consciousness Obtain a detailed history: ❑ Use of medications (prescription or over the counter) ❑ Compliance to anti-hypertensive medications if applicable ❑ Recreational drug use (methamphetamine, cocaine, phencyclidine) | ||||||||||||||||||||||||||||||
Examine the patient: ❑ Blood pressure ♦ Measured by the physician ♦ Both arms ♦ Appropriate cuff size ❑ Fundoscopic exam (looking for papilledema, exudates, hemorrhages) ❑ Complete neurological and mental status exam ❑ Cardiopulmonary signs of pulmonary edema, murmurs, gallops ❑ Abdomen (looking for pulsatile masses, tenderness, bruits) ❑ Peripheral pulses | ||||||||||||||||||||||||||||||
Order Labs: ❑ CBC ❑ Electrolytes
| ||||||||||||||||||||||||||||||
Evidence of end organ damage? | ||||||||||||||||||||||||||||||
YES | NO | |||||||||||||||||||||||||||||
Hypertensive emergency | Hypertensive urgency | |||||||||||||||||||||||||||||
❑ Admit to ICU[4] | ❑ Treat as outpatient or admit for observation | |||||||||||||||||||||||||||||
❑ Monitor the blood pressure closely
❑ Assess volume status
❑ Commence continuous infusion of short acting IV antihypertensives based on patient's end organ damage | ❑ Administer Oral antihypertensives ❑ Monitor the patient clinically within the first few hours of commencing medications NB - Gradual blood pressure reduction over 24 - 48 hours | |||||||||||||||||||||||||||||
Failure to control the blood pressure ❑ Consider a combination of antihypertensive medications | Good control of the blood pressure ❑ Review old or start new medications ❑ Modify risk factors ❑ Schedule a follow up | |||||||||||||||||||||||||||||
Intravenous Antihypertensive Drugs
Shown below is a table of the IV antihypertensive drugs and their appropriate doses.[5]
Drug | Dose |
---|---|
Clevidipine | 1 to 2 mg/h as IV infusion, max 16 mg/h |
Enalaprilat | 1.25–5 mg every 6 hrs IV |
Fenoldopam | 0.1–0.3 µg/kg per min IV infusion |
Hydralazine | 10–20 mg IV |
Nicardipine | 5–15 mg/h IV |
Nitroglycerin | 5–100 µg/min as IV infusion |
Nitroprusside | 0.25–10 µg/kg/min as IV infusion |
Esmolol | 250–500 µg/kg/min IV bolus, then 50–100 µg/kg/min by infusion May repeat bolus after 5 min or increase infusion to 300 µg/min |
Labetalol | 20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion |
Phentolamine | 5–15 mg IV bolus |
Oral Antihypertensive Drugs
Shown below is a table of the oral antihypertensive drugs and their appropriate doses.[5]
Drug | Dose |
---|---|
Captopril | 12.5 to 25 mg PO or SL, repeat as needed. max dose - 50 mg PO |
Clonidine | 0.1-0.2 mg PO x 1, then 0.05 to 0.1 mg/1-2 hrs. Max dose - 0.6 to 0.7 mg |
Labetalol | 200 mg PO, then 200 mg/hr until desired effect. Max dose - 1200 mg |
- Other agents to consider include:
- PO frusemide 20mg (repeat as necessary)
- PO nifedipine SR 30mg, single dose
- PO felodipine 5 mg, single dose
Management of Specific Hypertensive Emergencies
Hypertensive emergencies | Preferred agents |
---|---|
Aortic dissection | Labetalol, or nicardipine + esmolol, or nitroprusside + esmolol or nitroprusside + IV metoprolol Note: Administer beta blocker to control the heart rate before initiating a vasodilator e.g. nitroprusside
|
Acute pulmonary edema / systolic dysfunction | Nitroglycerin + (Nicardipine or, fenoldopam, or nitroprusside) + loop diuretic |
Acute pulmonary edema / diastolic dysfunction | Low-dose Nitroglycerin + (esmolol, metoprolol, labetalol, or verapamil) + loop diuretic |
Acute coronary syndrome | Nitroglycerin + (labetalol or esmolol) |
Hypertensive emergency with acute or chronic renal failure | Nicardipine or fenoldopam |
Hypertensive encephalopathy | Nicardipine, labetalol, fenoldopam Note: the blood pressure should not be lowered by more than 25% |
Pre-eclampsia / eclampsia | Labetalol or nicardipine |
Sympathetic crisis / cocaine overdose | Benzodiazepine + (verapamil, diltiazem, or nicardipine) Note: Beta blockers should NOT be administered alone to prevent un-opposed alpha-adrenergic stimulation |
Cerebrovascular accident | Nicardipine, labetalol, fenoldopam, or clevidipine Note: An expert's judgement is required to determine if the blood pressure should be lowered. |
Withdrawal of antihypertensive therapy e.g. clonidine or propanolol | Re-administer the discontinued drug; phentolamine, nitroprusside, or labetalol, if necessary |
Dos
- Hypertensive emergencies are best managed with a continuous infusion of short-acting titratable antihypertensive agents.
- Avoid sublingual and intramuscular routes of drug administration due to their unpredictable pharmacodynamics.
- Assess the patient' volume status before initiating intravenous vasodilators to prevent or minimize a substancial fall in blood pressure.[6]
Don'ts
- Don't consider nifedipine, nitroglycerin and hydralazine as first-line therapies in the management of hypertensive crises due to their potential toxicities and adverse effects.[4]
- Don't use intramuscular or sublingual antihypertensive medications in the case of hypertensive emergency.
- Don't use rapid acting antihypertensive if the patient is not in an ICU setting.
References
- ↑ 1.0 1.1 Chobanian, AV.; Bakris, GL.; Black, HR.; Cushman, WC.; Green, LA.; Izzo, JL.; Jones, DW.; Materson, BJ.; Oparil, S. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199. Unknown parameter
|month=
ignored (help) - ↑ "The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V)". Arch Intern Med. 153 (2): 154–83. 1993. PMID 8422206. Unknown parameter
|month=
ignored (help) - ↑ Varon J, Marik PE (2003). "Clinical review: the management of hypertensive crises". Crit Care. 7 (5): 374–84. doi:10.1186/cc2351. PMC 270718. PMID 12974970.
- ↑ 4.0 4.1 Varon, J. (2008). "Treatment of acute severe hypertension: current and newer agents". Drugs. 68 (3): 283–97. PMID 18257607.
- ↑ 5.0 5.1 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199.
- ↑ Marik, PE.; Varon, J. (2007). "Hypertensive crises: challenges and management". Chest. 131 (6): 1949–62. doi:10.1378/chest.06-2490. PMID 17565029. Unknown parameter
|month=
ignored (help)