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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Hypertensive Crisis Resident Survival Guide Microchapters}} | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertensive crisis resident survival guide#Overview|Overview]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertensive crisis resident survival guide#Causes|Causes]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertensive crisis resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertensive crisis resident survival guide#Complete Diagnostic Approach|Diagnosis]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertensive crisis resident survival guide#Treatment|Treatment]] | |||
: [[Hypertensive Crisis resident survival guide#Initial Treatment|Initial]] | |||
: [[Hypertensive Crisis resident survival guide#Treatment of Specific Supraventricular Arrhythmia|Specific]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertensive crisis resident survival guide#Do's|Do's]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertensive crisis resident survival guide#Don'ts|Don'ts]] | |||
|} | |||
==Overview== | |||
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.<ref name="-1993">{{Cite journal | title = The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) | journal = Arch Intern Med | volume = 153 | issue = 2 | pages = 154-83 | month = Jan | year = 1993 | doi = | PMID = 8422206 }}</ref> Hypertensive crisis includes both hypertensive emergency and hypertensive urgency. Noncompliance with [[hypertension medical therapy|antihypertensive medications]] is the most common cause of hypertensive crisis.<ref name="Stewart-2006">{{Cite journal | last1 = Stewart | first1 = DL. | last2 = Feinstein | first2 = SE. | last3 = Colgan | first3 = R. | title = Hypertensive urgencies and emergencies. | journal = Prim Care | volume = 33 | issue = 3 | pages = 613-23, v | month = Sep | year = 2006 | doi = 10.1016/j.pop.2006.06.001 | PMID = 17088151 }}</ref> | |||
==Classification== | |||
Hypertensive crisis can be further classified as hypertensive urgency and hypertensive emergency based on either the absence or presence of acute end-organ damage.<ref name="-1993">{{Cite journal | title = The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) | journal = Arch Intern Med | volume = 153 | issue = 2 | pages = 154-83 | month = Jan | year = 1993 | doi = | PMID = 8422206 }}</ref> | |||
===Hypertensive Urgency=== | |||
Hypertensive urgency is an acute severe elevation in the [[blood pressure]] without any evidence of acute end-organ damage. | |||
===Hypertensive Emergency=== | |||
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]], [[Congestive heart failure classification#Acute or Decompensated|acute left ventricular failure]] with [[pulmonary edema]], [[acute myocardial infarction]], [[acute renal failure]], or symptomatic [[microangiopathic hemolytic anemia]].<ref name="pmid12748199">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal=JAMA | year= 2003 | volume= 289 | issue= 19 | pages= 2560-72 | pmid=12748199 | doi=10.1001/jama.289.19.2560 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12748199 }} </ref> | |||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
[[Hypertensive crisis]] is a life-threatening condition and must be treated as such irrespective of the cause. | |||
===Common Causes=== | ===Common Causes=== | ||
* | * [[Hypertension medical therapy|Antihypertensive medications]] withdrawal ( [[beta blocker]]s, [[clonidine]]) | ||
* Noncompliance with [[hypertension medical therapy|antihypertensive medications]]<ref name="Stewart-2006">{{Cite journal | last1 = Stewart | first1 = DL. | last2 = Feinstein | first2 = SE. | last3 = Colgan | first3 = R. | title = Hypertensive urgencies and emergencies. | journal = Prim Care | volume = 33 | issue = 3 | pages = 613-23, v | month = Sep | year = 2006 | doi = 10.1016/j.pop.2006.06.001 | PMID = 17088151 }}</ref> | |||
* | |||
* [[Pheochromocytoma]] | * [[Pheochromocytoma]] | ||
* Side effects of [[monoamine oxidase inhibitor]]s | |||
* [[Stimulants]] ([[cocaine]], [[methamphetamine]], [[phencyclidine]]) | |||
It can develop de novo or can complicate essential or [[secondary hypertension]]. | |||
Click '''[[Essential hypertension causes|here]]''' for the complete list of causes of [[chronic hypertension]]. | |||
==FIRE: Focused Initial Rapid Evaluation== | |||
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. <br> | |||
<span style="font-size:85%">Boxes in the red color signify that an urgent management is needed.</span> | |||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | A01 | {{familytree | | | | | | A01 | | |A01=<div style="width:13em">'''Identify cardinal findings that suggest any of the following:'''</div><br><div style="width:18em; text-align:left"> | ||
{{familytree | | | | | |!| | |}} | ❑ [[Cerebral infarction]] and [[Intracerebral hemorrhage]]<br> | ||
{{familytree | | | | | B01 | | |B01=<div style=" | :❑ Lateralizing signs <br> | ||
{{familytree | | | | | | | ❑ [[Subarachnoid hemorrhage]]<br> | ||
{{familytree | :❑ Sudden severe [[headache]] <br> | ||
{{familytree | | | | | | | ❑ [[Hypertensive encephalopathy]]<br> | ||
{{familytree | | | | | D01 | | | |D01=''' | :❑ Altered level of consciousness<br> | ||
{{familytree | | | :❑ [[Hypertensive retinopathy]] (retinal hemorrhage and [[papilledema]])<br> | ||
{{familytree | | :❑ [[Seizures]] <br> | ||
{{familytree | ❑ [[Left ventricular failure|Acute left ventricular failure]]<br> | ||
{{familytree | | ❑ [[Myocardial infarction]]<br> | ||
{{familytree | :❑ [[Chest pain]] radiating to the jaw and left arm | ||
{{familytree | | :❑ Consider atypical presentations as [[dyspnea]], [[cough]], or [[fatigue]]<br> | ||
{{familytree | | | ❑ [[Aortic dissection]]<br> | ||
{{familytree | | :❑ Severe [[chest pain]], unequal pulses, [[widened mediastinum]] <br> | ||
❑ [[Pulmonary edema|Acute pulmonary edema]]<br> | |||
:❑ Severe [[dyspnea]], decreased breath sounds and rales <br> | |||
❑ [[Acute renal failure]] | |||
</div>}} | |||
{{familytree | | | | | | |!| | |}} | |||
{{familytree | | | | | | B01 | | |B01=<div style="width:em"> Measure the [[blood pressure]] </div>}} | |||
{{familytree | | | | |,|-|^|-|.| |}} | |||
{{familytree | | | | C01 | | C02 | |C01=<div style=" background: #FA8072; width: em"> {{fontcolor|#F8F8FF|'''BP ≥ 180/110'''}}</div>|C02='''BP < 180/110'''}} | |||
{{familytree | | | | |!| | | |!| | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | D01 | | D02 | |D01=<div style=" background: #FA8072; width: 13em"> {{fontcolor|#F8F8FF|Does the patient have any evidence of end organ damage?}}</div>|D02=<div style="text-align: left; background: ; height: px; width: 18em; line-height: px; padding: px;">❑ '''[[Chronic hypertension resident survival guide#Complete Diagnostic Approach|<span style="color:white;">Continue with the complete diagnostic approach of chronic hypertension</span>]]''' <br> ❑ '''Proceed with the specific managemnt of the different causes'''</div> }} | |||
{{familytree | | | |,|-|^|-|.| | | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | E01 | | E02 | |E01=<div style=" background: #FA8072; width: em"> {{fontcolor|#F8F8FF|Yes}}</div>|E02=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|No}}</div>}} | |||
{{familytree | | | |!| | | |!| | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | F01 | | F02 | |F01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|[[Hypertensive emergency|<span style="color:white;">'''Hypertensive emergency'''</span>]]}}</div>|F02=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|[[Hypertensive urgency|<span style="color:white;">'''Hypertensive urgency'''</span>]]}}</div>}} | |||
{{familytree | | | |!| | | |!| | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | B01 | | B02 | |B01=<div style=" background: #FA8072; text-align: left"> {{fontcolor|#F8F8FF|'''Identify alarming signs and symptoms:'''<br>❑ [[Tachycardia|<span style="color:white;">Tachycardia</span>]] <br> ❑ [[Hypotension|<span style="color:white;">Hypotension</span>]]<br> ❑ [[Loss of consciousness|<span style="color:white;">Loss of consciousness</span>]] | |||
<br>❑ [[Tachypnea|<span style="color:white;">Tachypnea</span>]]}}</div>|B02=<div style="float: left; text-align: left; width: 13em; padding:1em;">❑ Consider admission for observation <br>❑ Consider treatment as an outpatient </div>}} | |||
{{familytree | | | |`|-|v|-|'| | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | G01 | | |G01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF| [[Hypertensive crisis resident survival guide|<span style="color:white;">'''Click here for complete management of hypertensive crisis'''</span>]]}}</div>}} | |||
{{familytree/end}} | {{familytree/end}} | ||
=== | ==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.<ref name="pmid12748199">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal=JAMA | year= 2003 | volume= 289 | issue= 19 | pages= 2560-72 | pmid=12748199 | doi=10.1001/jama.289.19.2560 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12748199 }} </ref> | |||
! Onset of | {{familytree/start}} | ||
{{familytree | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Characterize the symptoms:'''<br>❑ A new complex of symptoms related to elevated blood pressure | |||
:❑ '''Central nervous system:''' (symptoms suggestive of [[cerebral infarction]], [[intracerebral hemorrhage|intracerebral]] or [[subarachnoid hemorrhage]], or [[hypertensive encephalopathy]]) | |||
::❑ Severe [[headache]] | |||
::❑ [[Altered mental status|Altered level of consciousness]] | |||
::❑ [[Confusion]] or [[agitation]] | |||
::❑ Difficulty in speaking or understanding | |||
::❑ [[Dysphagia]] | |||
::❑ [[Nausea]] or [[vomiting]] | |||
::❑ [[Dizziness]] | |||
::❑ Weakness or numbness | |||
::❑ Loss of balance or coordination | |||
::❑ [[Seizures]] | |||
::❑ [[Stupor]] or [[coma]] | |||
::❑ [[Asterixis]] | |||
::❑ [[Tremors]] | |||
:❑ '''Eyes:''' (symptoms suggestive of [[hypertensive retinopathy]]) | |||
::❑ [[Pain]] | |||
::❑ Blurred or loss of vision | |||
:❑ '''Cardiovascular system:''' (symptoms suggestive of [[Left ventricular failure|acute left ventricular failure]], [[myocardial infarction]], or [[aortic dissection]]) | |||
::❑ [[Chest pain]] | |||
::❑ [[Dyspnea]] | |||
::❑ [[Palpitations]] | |||
::❑ [[Back pain]] | |||
::❑ [[Pleuritic pain]] | |||
:❑ '''Respiratory system:''' (symptoms suggestive of [[Pulmonary edema|acute pulmonary edema]]) | |||
::❑ [[Cough]] with or without frothy sputum | |||
::❑ [[Cough]] with or without blood | |||
::❑ [[Dyspnea]] | |||
::❑ [[Diaphoresis]] | |||
::❑ [[Orthopnea]] | |||
::❑ [[Paroxysmal nocturnal dyspnea]] | |||
::❑ [[Wheezing]] | |||
:❑ '''Renal:''' (symptoms suggestive of [[acute renal failure]]) | |||
::❑ [[Hematuria]] | |||
::❑ Reduced urinary output | |||
:❑ '''Others:''' | |||
::❑ [[Anxiety]] | |||
::❑ [[Eclampsia]] (during pregnancy) | |||
::❑ [[Epistaxis]] </div>}} | |||
{{familytree | | | | |!| | | | | | | |}} | |||
{{familytree | | | | B01 | | | | | | |B01='''Consider the diagnosis of [[hypertensive crisis]]'''}} | |||
{{familytree | | | | |!| | | | | | | |}} | |||
{{familytree | | | | C01 | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Obtain a detailed history:'''<br> | |||
History of<br> | |||
❑ [[Hypertension]] | |||
:❑ Onset and duration | |||
:❑ Previous anti-hypertensive medications with dosing and duration of use | |||
:❑ Current anti-hypertensive medications with dosing duration of use | |||
:❑ Compliance to anti-hypertensive medications | |||
:❑ Time since the last dose of anti-hypertensive medication <br> | |||
❑ Other prescribed or over-the-counter medications (eg, [[monoamine oxidase inhibitors]], [[sympathomimetic agents]])<br> | |||
❑ Recreational drug use (eg, [[methamphetamine]], [[cocaine]], [[phencyclidine]]<br> | |||
❑ Any cerebrovascular disease<br> | |||
❑ Any cardiac disease<br> | |||
❑ Any renal disease<br> | |||
❑ Other medical problems (eg, thyroid disease, [[Cushing disease]], [[systemic lupus]])</div>}} | |||
{{familytree | | | | |!| | | | | | | | |}} | |||
{{familytree | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Examine the patient:'''<br> | |||
'''Vitals'''<br> | |||
❑ [[Pulse]]<br> | |||
:❑ [[Tachycardia]] <br> | |||
:❑ Unequal pulse (suggestive of [[aortic dissection]]) <br> | |||
:❑ Should be measured in all extremities <br> | |||
❑ [[Respiration]]<br> | |||
:❑ [[Tachypnea]] (suggestive of left sided [[heart failure]] or [[pulmonary edema]]) <br> | |||
❑ [[Blood pressure]]<br> | |||
:❑ [[Hypertension]] (systolic blood pressure ≥ 180 mm Hg, or diastolic blood pressure ≥ 120 mmHg) | |||
:❑ Measured by the physician <br> | |||
:❑ Measured in both arms <br> | |||
:❑ Measured with appropriate cuff size (small cuffs gives falsely high readings)<br> | |||
❑ [[Pulse oximetry]]<br> | |||
❑ [[Eye]]<br> | |||
:❑ [[Eye examination#Testing Extra-Ocular Movements:|Abnormal extra-ocular movements]] <br> | |||
:❑ [[Eye examination#Assessing Pupillary Response to Light:|Pupils not reactive to light]] <br> | |||
:❑ [[Eye examination#Using the Opthalmoscope|Abnormal findings on ophthalmoscopic exam]] <br> | |||
'''Neck'''<br> | |||
❑ Elevated [[jugular venous pressure]] (suggestive of [[heart failure]])<br> | |||
❑ [[Carotid bruits]] (suggestive of [[aortic stenosis]] and astherosclerotic vessels) <br> | |||
'''Respiratory examination'''<br> | |||
❑ Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles)<br> | |||
❑ Auscultation ([[rales]], reduced [[breath sounds]], [[egophony]]) (all suggestive of [[pulmonary edema]])<br> | |||
'''Cardiovascular examination'''<br> | |||
❑ Auscultation (abnormal sounds, murmurs) (suggestive of acute heart failure or previous heart disease)<br> | |||
❑ Abdominal aorta (e.g., size, bruits) (suggestive of [[aortic dissection]])<br> | |||
❑ Pedal pulses (e.g., pulse amplitude)<br> | |||
'''Abdominal examination'''<br> | |||
❑ looking for pulsatile masses, tenderness, bruits (suggestive of [[aortic dissection]] or renal artery involvement precipitating [[acute renal failure]])<br> | |||
'''Neurological examination'''<br> | |||
''Full neurological examination searching for laterlaizing signs'' (suggestive of cerebrovascular accident)<br> | |||
❑ [[Glasgow coma scale]] <br> | |||
❑ Test cranial nerves with notation of any deficits<br> | |||
❑ Deep tendon reflexes with notation of any pathologic reflexes (e.g., Babinksi)<br> | |||
:❑ [[Clonus]] <br> | |||
:❑ [[Hyperactive reflexes]] <br> | |||
❑ Sensation (e.g., by touch, pin, vibration, proprioception)<br> | |||
</div>}} | |||
{{familytree | | | | |!| | | | | |}} | |||
{{familytree | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 30em; 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> ❑ [[CT]] or [[MRI]] (in case of suspicion of aortic dissection) | |||
---- | |||
<table> | |||
<tr class="v-firstrow"><th>Consider additional tests based on each patient's presentation:<ref name="pmid12974970">{{cite journal| author=Varon J, Marik PE| title=Clinical review: the management of hypertensive crises. | journal=Crit Care | year= 2003 | volume= 7 | issue= 5 | pages= 374-84 | pmid=12974970 | doi=10.1186/cc2351 | pmc=PMC270718 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12974970 }} </ref></th></tr> | |||
<tr><td>❑ Urine [[electrolytes]], [[creatinine]], protein </td><td>❑ [[CT]]/[[MRI]]</td></tr> | |||
<tr><td>❑ Renal ultrasound + doppler </td><td> ❑ [[TSH]], free T3, free T4 </td></tr> | |||
<tr><td>❑ Serum [[cortisol]] </td><td> ❑ Serum [[aldosterone]] </td></tr> | |||
<tr><td>❑ Serum [[renin]] </td><td> ❑ 24-hr urinary [[catecholamine]] & [[metanephrine]] </td></tr> | |||
<tr><td>❑ Serum [[parathyroid hormone]] </td><td> ❑ Urine and serum [[toxicology]] screen </td></tr> | |||
<tr><td>❑ Urine [[pregnancy]] test </td><td>❑ [[ANA]]/[[ESR]]/[[CRP]]/anti-dsDNA/anti-smith/rheumatoid factor/p-ANCA/c-ANCA</td></tr> | |||
</table> | |||
</div>}} | |||
{{familytree/end}} | |||
<br> | |||
==Treatment== | |||
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.<ref name="pmid12748199">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal=JAMA | year= 2003 | volume= 289 | issue= 19 | pages= 2560-72 | pmid=12748199 | doi=10.1001/jama.289.19.2560 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12748199 }} </ref> | |||
<br> | |||
===Initial Approach=== | |||
! | {{familytree/start}} | ||
{{familytree | | | | F01 | | | |F01='''Is there any evidence of end organ damage?'''}} | |||
{{familytree | |,|-|-|^|-|-|.| | |}} | |||
{{familytree | G01 | | | | G02 | |G01='''YES'''|G02='''NO'''}} | |||
{{familytree | |!| | | | | |!| | | |}} | |||
{{familytree | F01 | | | | F02 | | |F01='''Hypertensive emergency'''<br>|F02='''Hypertensive urgency'''}} | |||
{{familytree | |!| | | | | |!| | | |}} | |||
{{familytree | F03 | | | | F04 | | | F03= ❑ Admit to ICU<ref name="Varon-2008">{{Cite journal | last1 = Varon | first1 = J. | title = Treatment of acute severe hypertension: current and newer agents. | journal = Drugs | volume = 68 | issue = 3 | pages = 283-97 | month = | year = 2008 | doi = | PMID = 18257607 }}</ref>| F04= ❑ Treat as outpatient or admit for observation}} | |||
{{familytree | |!| | | | | |!| | | |}} | |||
{{familytree | G01 | | | | G02 | | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Monitor the [[blood pressure]] closely | |||
:❑ Intra-arterial [[blood pressure]] monitoring in severely-ill patients<br> | |||
❑ Assess volume status | |||
:❑ IV N/S if volume depleted to prevent precipitous fall in [[blood pressure]] following administration of antihypertensives <br> | |||
❑ Commence continuous infusion of short acting [[Hypertensive crisis resident survival guide#Intravenous Antihypertensives|IV antihypertensives]] based on patient's end organ damage<br> | |||
❑ Change IV medications to oral when [[blood pressure]] is stable<br>'''NB - Not more than 25% reduction in [[blood pressure]] within the 1st hour; when [[blood pressure]] is stable, reduce to 160/100-110 mmHg within the next 2-6 hours'''<br> | |||
❑ When the patient is stable and the blood pressure is well tolerated, reduce the blood pressure to normal within 24-48 hours</div> | |||
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Administer [[hypertensive crisis resident survival guide#oral Antihypertensives|Oral antihypertensives]]<br>❑ Monitor the patient clinically within the first few hours of commencing medications<br> <br> '''NB - Gradual [[blood pressure]] reduction over 24 - 48 hours'''</div>}} | |||
{{familytree | | | | | |,|-|^|-|.| | |}} | |||
{{familytree | | | | | H01 | | H02 | |H01='''Failure to control the blood pressure'''<br>❑ Consider a combination of antihypertensive medications|H02=<div style="float: left; text-align: left; padding:1em;">'''Good control of the blood pressure'''<br>❑ Review old or start new medications<br>❑ Modify risk factors<br>❑ Schedule a follow up </div>}} | |||
{{familytree/end}} | |||
===Intravenous Antihypertensive Drugs=== | |||
Shown below is a table of the IV antihypertensive drugs and their appropriate doses.<ref name="pmid12748199">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal=JAMA | year= 2003 | volume= 289 | issue= 19 | pages= 2560-72 | pmid=12748199 | doi=10.1001/jama.289.19.2560 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12748199 }} </ref> | |||
{| Class="wikitable" | |||
! Drug | |||
! Dose | |||
|- | |- | ||
| [[Clevidipine]] | | [[Clevidipine]] | ||
| 1 to 2 mg/h as IV infusion, max 16 mg/h | | 1 to 2 mg/h as IV infusion, max 16 mg/h | ||
|- | |- | ||
| [[Enalaprilat]] | | [[Enalaprilat]] | ||
| 1.25–5 mg every 6 hrs IV | | 1.25–5 mg every 6 hrs IV | ||
|- | |- | ||
| [[Fenoldopam]] | | [[Fenoldopam]] | ||
| 0.1–0.3 µg/kg per min IV infusion | | 0.1–0.3 µg/kg per min IV infusion | ||
|- | |- | ||
|[[Hydralazine]] | |[[Hydralazine]] | ||
|10–20 mg IV | |10–20 mg IV | ||
|- | |- | ||
|[[Nicardipine]] | |[[Nicardipine]] | ||
|5–15 mg/h IV | |5–15 mg/h IV | ||
|- | |- | ||
|[[Nitroglycerin]] | |[[Nitroglycerin]] | ||
| 5–100 µg/min as IV infusion | | 5–100 µg/min as IV infusion | ||
|- | |- | ||
|[[Nitroprusside]] | |[[Nitroprusside]] | ||
|0.25–10 µg/kg/min as IV infusion | |0.25–10 µg/kg/min as IV infusion | ||
|- | |- | ||
|[[Esmolol]] | |[[Esmolol]] | ||
| 250–500 µg/kg/min IV bolus, then 50–100 µg/kg/min by infusion | | 250–500 µg/kg/min IV bolus, then 50–100 µg/kg/min by infusion<br> May repeat bolus after 5 min or increase infusion to 300 µg/min | ||
|- | |- | ||
|[[Labetalol]] | |[[Labetalol]] | ||
|20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion | |20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion | ||
|- | |- | ||
|[[Phentolamine]] | |[[Phentolamine]] | ||
|5–15 mg IV bolus | |5–15 mg IV bolus | ||
|} | |} | ||
===Oral Antihypertensive Drugs=== | |||
Shown below is a table of the oral antihypertensive drugs and their appropriate doses.<ref name="pmid12748199">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal=JAMA | year= 2003 | volume= 289 | issue= 19 | pages= 2560-72 | pmid=12748199 | doi=10.1001/jama.289.19.2560 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12748199 }} </ref> | |||
{| Class="wikitable" | {| Class="wikitable" | ||
! Drug | ! Drug | ||
! Dose | ! Dose | ||
|- | |- | ||
|[[Captopril]] | |[[Captopril]] | ||
|12.5 to 25 mg PO or SL, repeat as needed. max dose - 50 mg PO | |12.5 to 25 mg PO or SL, repeat as needed. max dose - 50 mg PO | ||
|- | |- | ||
|[[Clonidine]] | |[[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 | |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]] | |[[Labetalol]] | ||
|200 mg PO, then 200 mg/hr until desired effect. Max dose - 1200 mg | |200 mg PO, then 200 mg/hr until desired effect. Max dose - 1200 mg | ||
|} | |} | ||
* Other agents to consider include: | * Other agents to consider include: | ||
Line 211: | Line 297: | ||
!Hypertensive emergencies | !Hypertensive emergencies | ||
!Preferred agents | !Preferred agents | ||
|- | |- | ||
|Aortic dissection | |[[Aortic dissection]] | ||
| | |[[Labetalol]], or [[nicardipine]] + [[esmolol]], or [[nitroprusside]] + [[esmolol]] or [[nitroprusside]] + IV [[metoprolol]] <br> Note: '''Administer beta blocker to control the heart rate before initiating a vasodilator''' e.g. [[nitroprusside]] | ||
| | * Reduce [[blood pressure]] to '''120 mmHg''' within 20 minutes with protection against reflex tachycardia.<ref name="Chobanian-2003">{{Cite journal | last1 = Chobanian | first1 = AV. | last2 = Bakris | first2 = GL. | last3 = Black | first3 = HR. | last4 = Cushman | first4 = WC. | last5 = Green |first5 = LA. | last6 = Izzo | first6 = JL. | last7 = Jones | first7 = DW. | last8 = Materson | first8 = BJ. | last9 = Oparil | first9 = S. | title = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal = JAMA | volume = 289 | issue = 19 | pages = 2560-72 | month = May | year = 2003 | doi = 10.1001/jama.289.19.2560 | PMID = 12748199 }}</ref> | ||
|- | |- | ||
|Acute pulmonary edema/systolic dysfunction | |[[Pulmonary edema|Acute pulmonary edema]] / systolic dysfunction | ||
|Nitroglycerin + (Nicardipine or, fenoldopam, or nitroprusside) + loop diuretic | |||
| | |||
|- | |- | ||
|Acute pulmonary edema/diastolic dysfunction | |[[Pulmonary edema|Acute pulmonary edema]] / diastolic dysfunction | ||
|Low-dose Nitroglycerin + ([[esmolol]], [[metoprolol]], [[labetalol]], or [[verapamil]]) + loop diuretic | |||
| | |||
|- | |- | ||
|Acute coronary syndrome | |[[Acute coronary syndrome]] | ||
|[[Nitroglycerin]] + (labetalol or esmolol) | |||
| | |||
|- | |- | ||
|Hypertensive emergency with | |Hypertensive emergency with acute or chronic [[renal failure]] | ||
|[[Nicardipine]] or [[fenoldopam]] | |||
| | |||
|- | |- | ||
|Hypertensive encephalopathy | |[[Hypertensive encephalopathy]] | ||
| | |[[Nicardipine]], [[labetalol]], [[fenoldopam]] <br> Note: the [[blood pressure]] should not be lowered by more than 25% | ||
|- | |- | ||
|Pre-eclampsia/eclampsia | |[[Pre-eclampsia]] / [[eclampsia]] | ||
| | |[[Labetalol]] or [[nicardipine]] | ||
|- | |- | ||
|Sympathetic crisis | |[[Sympathetic crisis]] / [[cocaine overdose]] | ||
|[[Benzodiazepine]] + ([[verapamil]], [[diltiazem]], or [[nicardipine]]) <br> Note: Beta blockers should '''NOT''' be administered alone to prevent un-opposed alpha-adrenergic stimulation | |||
| | |||
|- | |- | ||
| | |[[Cerebrovascular accident]] | ||
|[[Nicardipine]], [[labetalol]], [[fenoldopam]], or [[clevidipine]] <br> Note: An expert's judgement is required to determine if the [[blood pressure]] should be lowered. | |||
| | |||
|- | |- | ||
|Withdrawal of antihypertensive therapy | |Withdrawal of antihypertensive therapy e.g. [[clonidine]] or [[propanolol]] | ||
| | |Re-administer the discontinued drug; [[phentolamine]], [[nitroprusside]], or [[labetalol]], if necessary | ||
|} | |} | ||
==Dos== | ==Dos== | ||
* Hypertensive emergencies are best managed with a continuous infusion of short-acting titratable antihypertensive agents. | * 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 | * Assess the patient' volume status before initiating intravenous vasodilators to prevent or minimize a substancial fall in [[blood pressure]].<ref name="Marik-2007">{{Cite journal | last1 = Marik | first1 = PE. | last2 = Varon | first2 = J. | title = Hypertensive crises: challenges and management. | journal = Chest | volume = 131 | issue = 6 | pages = 1949-62 | month = Jun | year = 2007 | doi = 10.1378/chest.06-2490 | PMID = 17565029 }}</ref> | ||
==Don'ts== | ==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.<ref name="Varon-2008">{{Cite journal | last1 = Varon | first1 = J. | title = Treatment of acute severe hypertension: current and newer agents. | journal = Drugs | volume = 68 | issue = 3 | pages = 283-97 | month = | year = 2008 | doi = | PMID = 18257607 }}</ref> | |||
* 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== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Line 272: | Line 348: | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
</div> |
Latest revision as of 20:03, 2 May 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]
Hypertensive Crisis Resident Survival Guide Microchapters |
---|
Overview |
Causes |
FIRE |
Diagnosis |
Treatment |
Do's |
Don'ts |
Overview
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.[1] Hypertensive crisis includes both hypertensive emergency and hypertensive urgency. Noncompliance with antihypertensive medications is the most common cause of hypertensive crisis.[2]
Classification
Hypertensive crisis can be further classified as hypertensive urgency and hypertensive emergency based on either the absence or presence of acute end-organ damage.[1]
Hypertensive Urgency
Hypertensive urgency is an acute severe elevation in the blood pressure without any evidence of acute end-organ damage.
Hypertensive Emergency
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.[3]
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[2]
- Pheochromocytoma
- Side effects of monoamine oxidase inhibitors
- Stimulants (cocaine, methamphetamine, phencyclidine)
It can develop de novo or can complicate essential or secondary hypertension. Click here for the complete list of causes of chronic hypertension.
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: ❑ Cerebral infarction and Intracerebral hemorrhage
❑ Acute left ventricular failure
| |||||||||||||||||||||||
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 | ||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||
Identify alarming signs and symptoms: ❑ Tachycardia ❑ Hypotension ❑ Loss of consciousness ❑ Tachypnea | ❑ 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.[3]
Characterize the symptoms: ❑ A new complex of symptoms related to elevated blood pressure
| ||||||||||||||||||||||||||||||
Consider the diagnosis of hypertensive crisis | ||||||||||||||||||||||||||||||
Obtain a detailed history: History of
❑ Other prescribed or over-the-counter medications (eg, monoamine oxidase inhibitors, sympathomimetic agents) | ||||||||||||||||||||||||||||||
Examine the patient: Vitals
❑ Pulse oximetry
Neck ❑ Sensation (e.g., by touch, pin, vibration, proprioception) | ||||||||||||||||||||||||||||||
Order Labs: ❑ CBC ❑ Electrolytes
| ||||||||||||||||||||||||||||||
Treatment
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.[3]
Initial Approach
Is there any evidence of end organ damage? | |||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||
Hypertensive emergency | Hypertensive urgency | ||||||||||||||||||||||||
❑ Admit to ICU[5] | ❑ 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.[3]
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.[3]
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.[7]
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.[5]
- 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 "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) - ↑ 2.0 2.1 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
|month=
ignored (help) - ↑ 3.0 3.1 3.2 3.3 3.4 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.
- ↑ 5.0 5.1 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
|month=
ignored (help) - ↑ 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)