Hypertensive crisis resident survival guide
|Hypertensive Crisis Resident Survival Guide Microchapters|
Hypertensive crisis is a term used to describe an acute elevation in the blood pressure which may or may not be associated with end-organ damage. Hypertensive crisis includes both hypertensive emergency and hypertensive urgency. Noncompliance with antihypertensive medications is the most common cause of hypertensive crisis.
Hypertensive crisis can be further classified as hypertensive urgency and hypertensive emergency based on either the absence or presence of acute end-organ damage.
Hypertensive urgency is an acute severe elevation in the blood pressure without any evidence of acute end-organ damage.
Hypertensive emergency mostly falls into stage 2 of hypertension (systolic blood pressure greater >160 mm Hg or diastolic blood pressure >100 mmHg). It is usually an acute severe elevation in the blood pressure (systolic blood pressure ≥ 180 mm Hg, or diastolic blood pressure ≥ 120 mmHg) 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.
Life Threatening Causes
Hypertensive crisis is a life-threatening condition and must be treated as such irrespective of the cause.
- Antihypertensive medications withdrawal ( beta blockers, clonidine)
- Noncompliance with antihypertensive medications
- Side effects of monoamine oxidase inhibitors
- Stimulants (cocaine, methamphetamine, phencyclidine)
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Boxes in the red color signify that an urgent management is needed.
Identify cardinal findings that suggest any of the following:
Measure the blood pressure
BP ≥ 180/110
|BP < 180/110|
Does the patient have any evidence of end organ damage?
❑ Continue with the complete diagnostic approach of chronic hypertension
❑ Proceed with the specific managemnt of the different causes
❑ Consider admission for observation
❑ Consider treatment as an outpatient
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.
Characterize the symptoms:
❑ A new complex of symptoms related to elevated blood pressure
|Consider the diagnosis of hypertensive crisis|
Obtain a detailed history:
❑ Other prescribed or over-the-counter medications (eg, monoamine oxidase inhibitors, sympathomimetic agents)
Examine the patient:
❑ Sensation (e.g., by touch, pin, vibration, proprioception)
Shown below is an algorithm summarizing the management of hypertensive crisis according to the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report.
|Is there any evidence of end organ damage?|
|Hypertensive emergency||Hypertensive urgency|
|❑ Admit to ICU||❑ 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
|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.
|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.
|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|
- 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.
- 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.
- 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.
- "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
- Stewart, DL.; Feinstein, SE.; Colgan, R. (2006). "Hypertensive urgencies and emergencies". Prim Care. 33 (3): 613–23, v. doi:10.1016/j.pop.2006.06.001. PMID 17088151. Unknown parameter
- 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.
- 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.
- Varon, J. (2008). "Treatment of acute severe hypertension: current and newer agents". Drugs. 68 (3): 283–97. PMID 18257607.
- 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
- 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