Hypertensive crisis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Definitions

• Hypertensive urgencies - These are severe elevations in blood pressure with no or minimal evidence of target organ damage. An example is a blood pressure of greater than 160/100 mmHg (stage 2 hypertension) associated with severe headache, shortness of breath, nosebleeds, or severe anxiety.

• Hypertensive emergencies - These are severe elevations in blood pressure, usually greater than 180/120 mmHg, complicated by evidence of impending or progressive target organ dysfunction. They warrant urgent blood pressure reduction by parenteral agents to prevent or limit target organ damage. This is a clinical diagnosis. Examples include: hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, e.t.c.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Management

Characterize the symptoms: ❑ CNS - severe headache, dizziness, confusion, weakness/numbness, altered/LOC, difficulty speaking ❑ Eyes - pain, blurred/loss of vision ❑ Cardiopulmonary - chest pain, dyspnea ❑ Renal - hematuria, proteinuria, reduced urinary output ❑ Others - nausea/vomiting, severe anxiety, nosebleeds

Evaluate the patient: ❑ History PMH especially HTN Medications - dosages, compliance Recreational drug use - methamphetamine, cocaine, phencyclidine ❑ Physical Blood pessure - both arms Fundoscopy - papilledema, exudates, hemorrhages Neuro exam - mental status, focal neurological deficits Cardiopulmonary - signs of pulmonary edema Abdomen - pulsatile masses, tenderness, bruits Limbs - peripheral pulses

Order Labs: ❑ CBC ❑ BMP + Mg + PO4 ❑ Serum uric acid ❑ FLP ❑ FBS ❑ Urinalysis/culture ❑ Urine electrolytes, creatinine, protein ❑ Chest X-ray ❑ EKG, ECHO ❑ Renal USS + 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 ICU 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 IV antihypertensives based on patient's symptom ↓ 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

Special considerations Malignant hypertension/Hypertensive encephalopathy Cerebrovascular accident Acute pulmonary edema Acute aortic dissection Angina pectoris/Acute MI Sympathetic crisis Preeclampsia/Eclampsia Withdrawal of antihypertensive medication Acute post-op hypertension

Worsening blood pressure

Good control Review old/start new medication Modify risk factors Close follow-up