Hypertensive crisis resident survival guide: Difference between revisions
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❑ [[Blood pressure]] <br>♦ Measured by the physician <br>♦ Both arms <br>♦ Appropriate cuff size <br>❑ [[Fundoscopy|Fundoscopic exam]] (looking for [[papilledema]], [[exudates]], [[hemorrhage]]s)<br> Complete neurological and [[mental status]] exam<br>❑ Cardiopulmonary signs of [[pulmonary edema]], [[murmur]]s, gallops<br>❑ Abdomen (looking for pulsatile masses, tenderness, bruits)<br>❑ Peripheral [[pulse]]s</div>}} | ❑ [[Blood pressure]] <br>♦ Measured by the physician <br>♦ Both arms <br>♦ Appropriate cuff size <br>❑ [[Fundoscopy|Fundoscopic exam]] (looking for [[papilledema]], [[exudates]], [[hemorrhage]]s)<br> Complete neurological and [[mental status]] exam<br>❑ Cardiopulmonary signs of [[pulmonary edema]], [[murmur]]s, gallops<br>❑ Abdomen (looking for pulsatile masses, tenderness, bruits)<br>❑ Peripheral [[pulse]]s</div>}} | ||
{{familytree | | | | | |!| | | | | |}} | {{familytree | | | | | |!| | | | | |}} | ||
{{familytree | | | | | C01 |-| C02 | | |C01=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;">'''Order Labs:'''<br> ❑ CBC<br>❑ | {{familytree | | | | | C01 |-| C02 | | |C01=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;">'''Order Labs:'''<br> ❑ [[CBC]]<br> | ||
❑ [[Electrolytes]] <br> ❑ [[BUN]] <br> ❑ [[Creatinine]]<br>❑ EKG (in case of chest pain) ❑ [[CXR]] ( in case of chest pain or dyspnea)<br> ❑ [[CT]] or [[MRI]] (in case of suspicion of aortic dissection) | |||
---- | |||
'''Consider additional tests based on each patient's presentation:''' <br> | |||
❑ Urine [[electrolytes]], [[creatinine]], protein<br> ❑ [[Echocardiography]] <br> ❑ Renal ultrasound + doppler</div>|C02=<div style="float: left; text-align: left; height: 22em; width: 20em; padding:1em;">'''Further work-up:'''<br> ❑ TSH, free T3, free T4<br> ❑ Serum cortisol<br> ❑ Serum aldosterone<br> ❑ Serum renin levels<br> ❑ HbA1C<br> ❑ 24-hr urinary catecholamine & metanephrine levels<br> ❑ Serum parathyroid hormone levels<br> ❑ Urine and serum toxicology screen<br> ❑ Urine pregnancy test<br> ❑ CT/MRI<br> ❑ DMSA/DTPA scans (renal scars)<br> ❑ ANA/ESR/CRP/anti-dsDNA/anti-smith/rheumatoid factor/p-ANCA/c-ANCA</div>}} | |||
{{familytree | | | | | |!| | | | |}} | {{familytree | | | | | |!| | | | |}} | ||
{{familytree | | | | | D01 | | | |D01='''Evidence of end organ damage''' (any of the symptoms above)}} | {{familytree | | | | | D01 | | | |D01='''Evidence of end organ damage''' (any of the symptoms above)}} | ||
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{{familytree | F01 | | | | | | F02 | | |F01=Hypertensive emergency<br>('''NB - Treat the patient and not the BP''')|F02=Hypertensive urgency}} | {{familytree | F01 | | | | | | F02 | | |F01=Hypertensive emergency<br>('''NB - Treat the patient and not the BP''')|F02=Hypertensive urgency}} | ||
{{familytree | |!| | | | | | | |!| | | |}} | {{familytree | |!| | | | | | | |!| | | |}} | ||
{{familytree | G01 |-|.| | | | G02 | | |G01=<div style="float: left; text-align: left; height: 26em; width: 20em; padding:1em;"><u>'''Admit 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></u><br>Close BP monitoring<br>↓<br>Intra-arterial BP monitoring in severely-ill patients<br>↓<br>Assess volume status - IV N/S if volume depleted to prevent precipitous fall in BP following administration of antihypertensives<br>↓<br>Commence continuous infusion of short acting [[Hypertensive crisis resident survival guide#Intravenous Antihypertensives|IV antihypertensives]] based on patient's end organ damage<br>↓<br>Change IV meds to oral when BP is stable<br>'''NB - Not more than 25% reduction in BP within the 1st hour; when BP is stable, reduce to 160/100-110 mmHg within the next 2-6 hours'''</div>|G02=<div style="float: left; text-align: left; height: 26em; width: 20em; padding:1em;"><u>'''Outpatient/Admit for observation'''</u><br>[[Hypertensive crisis resident survival guide#Oral Antihypertensives|Oral antihypertensives]]<br>Clinical surveillance within the first few hours of commencing medications<br>'''NB - Gradual BP reduction over 24 - 48 hours'''</div>}} | {{familytree | G01 |-|.| | | | G02 | | |G01=<div style="float: left; text-align: left; height: 26em; width: 20em; padding:1em;"><u>'''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></u><br>Close BP monitoring<br>↓<br>Intra-arterial BP monitoring in severely-ill patients<br>↓<br>Assess volume status - IV N/S if volume depleted to prevent precipitous fall in BP following administration of antihypertensives<br>↓<br>Commence continuous infusion of short acting [[Hypertensive crisis resident survival guide#Intravenous Antihypertensives|IV antihypertensives]] based on patient's end organ damage<br>↓<br>Change IV meds to oral when BP is stable<br>'''NB - Not more than 25% reduction in BP within the 1st hour; when BP is stable, reduce to 160/100-110 mmHg within the next 2-6 hours'''</div>|G02=<div style="float: left; text-align: left; height: 26em; width: 20em; padding:1em;"><u>'''Outpatient/Admit for observation'''</u><br>[[Hypertensive crisis resident survival guide#Oral Antihypertensives|Oral antihypertensives]]<br>Clinical surveillance within the first few hours of commencing medications<br>'''NB - Gradual BP reduction over 24 - 48 hours'''</div>}} | ||
{{familytree | |!| | |!| | |,|-|^|-|.| | |}} | {{familytree | |!| | |!| | |,|-|^|-|.| | |}} | ||
{{familytree | H01 | |`|-| H02 | | H03 | |H01=[[Hypertensive crisis resident survival guide#Management of Specific Hypertensive Emergencies|Management of specific hypertensive emergencies]]|H02=Worsening blood pressure|H03=<u>'''Good control'''</u><br>Review old/start new medication<br>'''Modify risk factors'''<br>Close follow-up}} | {{familytree | H01 | |`|-| H02 | | H03 | |H01=[[Hypertensive crisis resident survival guide#Management of Specific Hypertensive Emergencies|Management of specific hypertensive emergencies]]|H02=Worsening blood pressure|H03=<u>'''Good control'''</u><br>Review old/start new medication<br>'''Modify risk factors'''<br>Close follow-up}} |
Revision as of 20:51, 10 January 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]
Definitions
- Hypertensive urgency is the severe elevation in the blood pressure (systolic blood pressure>160 mmHg, or diastolic blood pressure>100 mmHg) with no or minimal evidence of target organ damage.[1]
- Hypertensive emergency is the severe elevation in the blood pressure, usually greater than 180/120 mmHg, complicated by evidence of impending or progressive target organ dysfunction, such as hypertensive encephalopathy, intracerebral hemorrhage and acute myocardial infarction.[1]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Hypertensive crisis is a life-threatening condition and must be treated as such irrespective of the cause.
Common Causes
- Antihypertensives 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 ❑ Past medical history of HTN ❑ 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 Consider additional tests based on each patient's presentation: ❑ Echocardiography ❑ Renal ultrasound + doppler | Further work-up: ❑ TSH, free T3, free T4 ❑ Serum cortisol ❑ Serum aldosterone ❑ Serum renin levels ❑ HbA1C ❑ 24-hr urinary catecholamine & metanephrine levels ❑ Serum parathyroid hormone levels ❑ Urine and serum toxicology screen ❑ Urine pregnancy test ❑ CT/MRI ❑ DMSA/DTPA scans (renal scars) ❑ ANA/ESR/CRP/anti-dsDNA/anti-smith/rheumatoid factor/p-ANCA/c-ANCA | ||||||||||||||||||||||||||||
Evidence of end organ damage (any of the symptoms above) | |||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||
Hypertensive emergency (NB - Treat the patient and not the BP) | Hypertensive urgency | ||||||||||||||||||||||||||||
Admit to ICU[2] Close BP monitoring ↓ Intra-arterial BP monitoring in severely-ill patients ↓ Assess volume status - IV N/S if volume depleted to prevent precipitous fall in BP following administration of antihypertensives ↓ Commence continuous infusion of short acting IV antihypertensives based on patient's end organ damage ↓ Change IV meds to oral when BP is stable NB - Not more than 25% reduction in BP within the 1st hour; when BP is stable, reduce to 160/100-110 mmHg within the next 2-6 hours | Outpatient/Admit for observation Oral antihypertensives Clinical surveillance within the first few hours of commencing medications NB - Gradual BP reduction over 24 - 48 hours | ||||||||||||||||||||||||||||
Management of specific hypertensive emergencies | Worsening blood pressure | Good control Review old/start new medication Modify risk factors Close follow-up | |||||||||||||||||||||||||||
Intravenous Antihypertensives
Drug | Dose | Onset of action | Duration of action | Special indication | Avoid use |
---|---|---|---|---|---|
Clevidipine | 1 to 2 mg/h as IV infusion, max 16 mg/h | 2-4 mins | 5-15 mins | Most HE | ----- |
Enalaprilat | 1.25–5 mg every 6 hrs IV | 15–30 | 6–12 hrs | Acute left ventricular failure | AMI, renal impairment, pregnancy. No benefit in HE. |
Fenoldopam | 0.1–0.3 µg/kg per min IV infusion | <5 min | 30 min | Most HE + renal insufficiency | Glaucoma or ↑ICP |
Hydralazine | 10–20 mg IV | 10–20 min IV | 1–4 hrs | Eclampsia; although labetalol or nicardipine is preferred | This should generally be avoided due to its unpredictable pharmacodynamics |
Nicardipine | 5–15 mg/h IV | 5–10 min | 1.5 - ≥4 hrs | Most HE esp post-op hypertension, aortic dissection & pregnancy | Acute heart failure. Caution with cirrhotics & coronary ischemia |
Nitroglycerin | 5–100 µg/min as IV infusion | 2–5 min | 5–10 min | Coronary ischemia, cardiogenic pulmonary edema | Not used for most HE |
Nitroprusside | 0.25–10 µg/kg/min as IV infusion | Immediate | 1–2 min | Most HE; should be avoided due to its toxicity (cyanide toxicity) | Caution with ↑ICP, AMI, CAD, CVA, renal or hepatic impairment. |
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 | 1–2 min | 10–30 min | Aortic dissection, perioperative (to reduce reflex tachycardia) | Acute decompensated heart failure |
Labetalol | 20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion | 5–10 min | 3–6 hrs | Most HE; used in combination with vasodilators to reduces reflex tachycardia | Acute decompensated heart failure, heart block, asthma, pheochromocytoma |
Phentolamine | 5–15 mg IV bolus | 1–2 min | 10–30 min | Catecholamine excess |
- HE - Hypertensive emergencies
Oral Antihypertensives
Drug | Dose | Onset of action | Duration of action |
---|---|---|---|
Captopril | 12.5 to 25 mg PO or SL, repeat as needed. max dose - 50 mg PO | 5-15 mins | 2-6 hrs |
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 | 15-30 mins | 2-8 hrs |
Labetalol | 200 mg PO, then 200 mg/hr until desired effect. Max dose - 1200 mg | 2 hrs | 4 hrs |
- 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 | NTG + (Nicardipine or, fenoldopam, or nitroprusside) + loop diuretic |
Acute pulmonary edema/diastolic dysfunction | Low-dose NTG + (esmolol, metoprolol, labetalol, or verapamil) + loop diuretic |
Acute coronary syndrome | NTG + (labetalol or esmolol) |
Hypertensive emergency with ARF/CRF | Nicardipine or fenoldopam |
Hypertensive encephalopathy | Nicardipine, labetalol, fenoldopam Note: The BP 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 BP 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.
- Both sublingual and intramuscular routes of drug administration should be avoided due to their unpredictable pharmacodynamics.
- Assess patients' volume status before commencing intravenous vasodilators to prevent/minimize precipitous fall in blood pressure.[3]
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.[2]
- 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 1.2 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) - ↑ 2.0 2.1 Varon, J. (2008). "Treatment of acute severe hypertension: current and newer agents". Drugs. 68 (3): 283–97. PMID 18257607.
- ↑ 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)