Hypertensive crisis resident survival guide: Difference between revisions
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{{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 | 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 | |!| | | | | |!| | | |}} | ||
{{familytree | G01 | | | | G02 | | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Close | {{familytree | G01 | | | | G02 | | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Close [[blood pressure]] monitoring | ||
:❑ Intra-arterial | :❑ Intra-arterial [[blood pressure]] monitoring in severely-ill patients<br> | ||
❑ Assess volume status | ❑ Assess volume status | ||
:❑ IV N/S if volume depleted to prevent precipitous fall in | :❑ 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> | ❑ 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 | ❑ 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> | ❑ 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 | |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 | | | | | |,|-|^|-|.| | |}} | ||
{{familytree | | | | | H01 | | H02 | |H01='''Failure to control the blood pressure'''<br>❑ Consider a combination of antihypertensive medications|H02='''Good control of the blood pressure'''<br>❑ Review old or start new medications<br>❑ Modify risk factors<br>❑ Schedule a follow up <br>}} | {{familytree | | | | | H01 | | H02 | |H01='''Failure to control the blood pressure'''<br>❑ Consider a combination of antihypertensive medications|H02='''Good control of the blood pressure'''<br>❑ Review old or start new medications<br>❑ Modify risk factors<br>❑ Schedule a follow up <br>}} | ||
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|[[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]] | |[[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 | * 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> | ||
|- | |- | ||
|[[Pulmonary edema|Acute pulmonary edema]] / systolic dysfunction | |[[Pulmonary edema|Acute pulmonary edema]] / systolic dysfunction |
Revision as of 02:05, 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. 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] | ❑ Treat as outpatient or admit for observation | |||||||||||||||||||||||||||||
❑ Close blood pressure monitoring
❑ 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.[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 Antihypertensive Drugs
Shown below is a table of the oral antihypertensive drugs and their appropriate doses.[4]
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.[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 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.
- ↑ 4.0 4.1 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)