Hypertensive crisis resident survival guide: Difference between revisions
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==Management== | ==Management== | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left | {{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 | ||
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❑ Past medical history of [[HTN]]<br>❑ Use of medications (prescription or over the counter) <br> ❑ Compliance to anti-hypertensive medications if applicable <br>❑ Recreational drug use ([[methamphetamine]], [[cocaine]], [[phencyclidine]]) </div>}} | ❑ Past medical history of [[HTN]]<br>❑ Use of medications (prescription or over the counter) <br> ❑ Compliance to anti-hypertensive medications if applicable <br>❑ Recreational drug use ([[methamphetamine]], [[cocaine]], [[phencyclidine]]) </div>}} | ||
{{familytree | | | | |!| | |}} | {{familytree | | | | |!| | |}} | ||
{{familytree | | | | B01 | | |B01=<div style="float: left; text-align: left | {{familytree | | | | B01 | | |B01=<div style="float: left; text-align: left; width: 40em; padding:1em;">'''Examine the patient:'''<br> | ||
❑ [[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 | | | |C01=<div style="float: left; text-align: left | {{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> ❑ [[CT]] or [[MRI]] (in case of suspicion of aortic dissection) | ❑ [[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) | ||
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{{familytree | F01 | | | | F02 | | |F01='''Hypertensive emergency'''<br>|F02='''Hypertensive urgency'''}} | {{familytree | F01 | | | | F02 | | |F01='''Hypertensive emergency'''<br>|F02='''Hypertensive urgency'''}} | ||
{{familytree | |!| | | | | |!| | | |}} | {{familytree | |!| | | | | |!| | | |}} | ||
{{familytree | G01 | | | | G02 | | |G01=<div style="float: left; text-align: left | {{familytree | G01 | | | | G02 | | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ '''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><br>❑ Close BP monitoring | ||
:❑ Intra-arterial BP monitoring in severely-ill patients<br> | :❑ Intra-arterial BP monitoring in severely-ill patients<br> | ||
❑ Assess volume status | ❑ Assess volume status | ||
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❑ Change IV medications 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'''<br> | ❑ Change IV medications 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'''<br> | ||
❑ When the patient is stable and the blood pressure is well tolerated, reduce the blood pressure to normal within 24-48 hours</div> | ❑ 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 | |G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ '''Treat as outpatient or admit for observation'''<br>❑ 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 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='''Failure to control the blood pressure'''<br>❑ Consider combination of | {{familytree | H01 | | H02 | | H03 | |H01=[[Hypertensive crisis resident survival guide#Management of Specific Hypertensive Emergencies|Management of specific hypertensive emergencies]]|H02='''Failure to control the blood pressure'''<br>❑ Consider a combination of antihypertensive medications|H03='''Good control of the blood pressure'''<br>❑ Review old or start new medications<br>❑ Modify risk factors<br>❑ Schedule a follow up <br>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 01:40, 16 February 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 acute target organ damage.[1]
- Hypertensive emergency is the severe elevation in the blood pressure (systolic blood pressure>180 mmHg, or diastolic blood pressure>120 mmHg) complicated acute 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 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[3] ❑ Close BP monitoring
❑ Assess volume status
❑ Commence continuous infusion of short acting IV antihypertensives based on patient's end organ damage | ❑ Treat as outpatient or admit for observation ❑ Administer Oral antihypertensives ❑ Monitor the patient clinically within the first few hours of commencing medications NB - Gradual BP reduction over 24 - 48 hours | |||||||||||||||||||||||||||||
Management of specific hypertensive emergencies | 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 Antihypertensives
Shown below is a table of the IV antihypertensive drugs and their appropriate doses.[4]
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 Antihypertensives
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 | 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.[5]
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.[3]
- 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) - ↑ 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.
- ↑ 3.0 3.1 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; 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)