HYPERTENSIVE EMERGENCIES

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HYPERTENSIVE EMERGENCIES

• Trevor Langhan PGY-2
• September 2, 2004

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CASE

• 67 y male
• Known small cell lung CA, prev CVA, DM, COPD,
  chronic steroids.
• Admitted to CCU one month ago with ACS
• Today was at TBCC getting CT scan for malignancy
  staging
• Brought directly by wife after acute c/o SOB and
  mild chest pain

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CASE

• BP 190/100, HR 140, RR 33, sats 81 r/a
• Working hard to breathe, mottled skin,
  diaphoretic
• Doesnt want to lay down for EKG, IV pokes
• Swollen legs R gt L
• Portable CXR
• RUL consolidation ?collapse
• Increased vascular markings bilaterally

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CASE

• Further Hx
• Received 2 units PRBC 3 days prior
• Chemotherapy yesterday with large volume load
• Volume of fluid IV with contrast for CT
• Known LV dysfunction from prev echo
• Documented LEVEL II care in chart (NO intub)
• Clinical exam
• accessory muscle use
• elevated JVP
• inspiratory/expiratory wheezes bilat
• minimal air entry

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CASE (our management)

• Unable to get IV access
• Couple/three NTG SL sprays
• ABG - 7.09/61/98/30
• Move to code room
• Femoral langhan i mean line

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CASE (our management)

• Started on BIPAP
• Medications
• IV NTG
• 5 ug/min to maximum 100 ug/min (we went to 200
  ug/min and he improved)
• Mechanism venous and mild arteriolar dilator
• IV Lasix
• 40 mg x 2
• Any better than oral?

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CASE (our management)

• We chose venous and arteriolar vasodilatation
  lasix
• labetalol
• decrease cardiac contractility
• COPD
• Known previous bronchospasm
• Hydralazine
• increase cardiac work, causes alpha blockade

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Pulmonary edema

• Pts with CHF usually have increased PVR
• Acute elevations in their BP may be secondary to
  hypoxia and subsequent catecholamine release
• Aggressive treatment of the pulmonary edema will
  help decrease the BP
• Nitrates
• Morphine
• Lasix
• Oxygen

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Hypertension

• HTN will present to the ED in a variety of ways
• 1. Hypertensive crisis/emergency
• 2. Hypertensive urgency
• 3. Mild hypertension without EOD
• 4. Transient hypertension

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Hypertensive Emergency

• Severely elevated blood pressure with signs of
  acute damage to target organs
• Brain, eyes, heart, kidneys

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Hypertensive Emergency

• Conditions defined by Rosens as HE
• Malignant hypertension
• Hypertensive encephalopathy
• Microangiopathic hemolytic anemia
• Acute renal failure
• Aortic dissection
• Eclampsia/preeclampsia
• Severe HTN in setting of
• MI
• Left ventricular failure
• Bleeding
• Thrombolytic therapy

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Hypertensive Urgency

• Situation where blood pressure elevation is an
  imminent risk for target-organ damage
• No acute end organ damage but risk is high if BP
  elevation continues
• Relative increase in BP more important than
  specific numbers

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Brief pathophysiology

• Mild to moderate increase in BP leads to initial
  vasoconstriction
• autoregulation
• Maintains perfusion at relatively stable level
• Prevents increased pressure from being
  transmitted downstream to smaller vessels
• As BP further increases, autoregulation fails
• Elevated BP disrupts vasc endothelium, causing
  narrowing

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Brief pathophysiology

• Chronic increase in BP causes arteriolar
  hypertrophy
• Will decrease the amount of pressure passed on to
  more distal vessels
• Chronically hypertense people need diastolic BPs
  gt130 for symptoms
• Normotensive people can have hypertensive crisis
  at DBP gt 100

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Case 2

• 45 y male c/o 12 hour history of SOBOE, mild
  chest heaviness
• Vomiting, drowsy
• Bi-frontal headache
• Blurred vision both eyes
• BP 240/150, HR 102, RR 16, sats 95

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Case 2

• PMHx ? HTN, was on a water pill many years
  ago. No DM, no CAD, generally healthy
• Labs normal, except Creat 150
• DDx? Mgnt?

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Case 2

• Goal of therapy is to reduce MAP by 25 in the
  first hour
• Keeping DBP gt 110 mmHg
• Reduction to pts relative normal BP by 4-6 hours
  is more long term goal
• What agents?
• Nitroprusside - 0.25-0.5 ug/kg/min, up to 10
  ug/kg/min, titratable, easy off, potential
  toxicity
• labetalol infusion 0.5-2 mg/min, or bolus 20 mg
  then 20-80 mg q 10 minutes (up to 300mg), alpha
  and beta blocker

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Hypertensive Encephalopathy

• Cerebral edema by breakthrough hyper-perfusion
  from severe and sudden increase BP
• BP has exceeded the capacity of autoregulation
• Elevated BP in vessels that cant accommodate the
  pressure leakage and edema
• Autoregulation must be considered during
  treatment
• I.e. Hypertrophied vessels cant vasodilate, so
  caution with lowering blood pressure to avoid a
  relative hypoperfusion and resultant ischemia

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Hypertensive Encephalopathy

• HE is a true medical emergency
• Is an acute presentation, but reversible
• Progression of untreated cerebral edema leads to
  coma and death
• Admission and invasive BP monitoring is the
  recommended mainstay of therapy

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Case 3

• 67 y female known CAD, DM, smoker, atrial fib.
• Presents with c/o weakness left side
• BP 160/100, HR 94, RR 14, sats 99
• O/E left facial droop, markedly weak left
  upper/lower extremity
• EKG a fib, nil acute
• Chest exam unremarkable

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Case 3

• Management?
• How do you treat her elevated BP?

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Stroke syndromes

• Most patients with this presentation are ischemic
  strokes (85) not hemorrhagic
• Likely dont have acutely elevated BP
• caution with lowering BP as Watershed area
  sensitive to hypoperfusion
• Lowering BP may worsen ischemic brain injury

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Stroke syndromes

• Rarely may see stoke with grossly elevated DBP gt
  140
• Pts receiving reperfusion therapy may require BP
  reduction, as BP gt 185/110 is contraindication to
  tPA
• What do you think about nitroprusside here?
• Titrate labetalol diligently in 5 mg increments
  to achieve slow decrease in MAP by a max of 20

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Case 4

• 32 y female awaiting sweatgland surgery from
  plastics for hyperhydrosis, c/o H/A, palpitations
• BP 170/90, HR 150 sinus, RR 18
• Otherwise healthy
• Treatment
• Nitroprusside if emergency
• Phentolamine 1-5 mg IV boluses (alpha-block)
• Followed by beta-blockade

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Case 4

• Pheochromocytoma
• Rare tumor 0.2 of pts with essential HTN
• Episodic H/A, tachycardia, sweating, HTN
• Tumor secreting norepinephrine and epinephrine
• Diagnosis radiographic, measurement of urinary
  and plasma levels of catecholamines and
  metabolites

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Case 5

• 25 y G2P1, LMP 6 months ago
• When do you treat HTN in pregnancy?
• DBP gt 110
• SBP gt 160
• Treat to goal of 140-155 and 90-105
• What agents?
• Hydralazine (older agent of choice)
• Labetalol (preferred modality now)

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Case 6

• 33 year male stock broker. Snorted a couple of
  rails of cocaine ½ hour ago.
• Presents with crushing retrosternal chest pain,
  diaphoresis and H/A
• BP 190/100, HR 130, RR 28, sats 96
• EKG ST segment elevation V1-V3
• Nurse asks what do you want to give?

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Case 6

• Give MONA
• You order IV metoprolol to be hung
• Before the Beta blocker, any concerns?
• Beta antagonism will decrease heart rate, but
  will also block B2 receptors
• Will have unopposed alpha agonism by cocaine
  toxicity dangerous HTN crisis
• Need alpha blockade first
• Like pheo can use phentolamine, some sources say
  hydralazine

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Case 7

• 55 year male smoker, HTN, DM, unstable angina
  getting worse.
• Shoveling snow and developed left RSCP that
  radiated to his jaw.
• HR 120, BP 190/90, RR 19, sats 99
• EKG obvious ant/lateral infarct
• How do you treat his pressure?

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Case 7

• Agents of choice in HTN during ACS
• Immediate lowering of BP indicated to prevent
  myocardial damage
• Also lower BP if pt to undergo reperfusion tx
• NTG agent of choice
• Beta block
• ACE-I (shown improvement in mortality)
• CCB (if BB is contraindicated)
• Anything thats contraindicated?
• Hydralazine reflex tachycardia
• Nitroprusside reflex tachycardia

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Hypertension

• What is normal BP?
• SBP lt 140
• DBP lt 90
• What is hypertension?
• SBP gt160
• DBP gt100
• Anything in between GRAY.

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Hypertension

• Possible cardiovascular causes of increased BP
• Loss of vessel elasticity with age
• Coarctation of aorta
• Delayed femoral pulses
• Hypertensive upper extremities
• Bruit in upper back

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Hypertension

• Endocrine causes for elevated BP
• Pheo
• Excess steroids
• Often iatrogenic
• Cushings
• Look for hypokalemia
• Volume overload from Na retention

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Hypertension

• Other causes include
• Withdrawal of sedative drugs
• EtOH, benzo
• Tyramine toxicity in MAO-I patients
• Aortic dissection
• Sympathomimmetic drug intoxication
• Withdrawal of clonidine or beta blocking agents
• Reno-vascular disease
• Renin-angiotensin system abnormality

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Drug choices
drug dose onset duration indication Contra-indication
nitroprusside 0.3-10 ug/kg/min 1-2 min 1-2 min Any hypertensive emergency Pregnancy Prolong use Renal failure
nitroglycerin 10-100 ug/kg/min 2-5 min 3-5 min AMI, CHF
hydralazine 5 mg 5-10mg q20min 10-20 min 3-8 h pregnancy AMI, aortic dissection
esmolol 500ug/kg then 50-300 ug/kg/min 1-2 min 10-20 min CAD, aortic dissection CHF, heart block, asthma, catecholamine excess
labetalol 20mg then 20-80 q10 min to max 300 OR 1-2 mg/min 2-10 min 2-4 h CAD, aortic dissection, eclampsia, hypertensive crisis CHF, heart block, asthma, catecholamine excess
phentolamine 5 mg q 1-2 min 1-2 min 10-30 min Catecholamine excess AMI
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Key concepts

• Presence of acute target organ damage determines
  HTN crisis
• All pts with persistent elevation of BP should be
  investigated of EOD
• ER doc should be familiar with indications and
  contraindications of meds to treat HTN crisis
• Goal of treat is relative decrease in MAP of 25
  in first hour, DBP should not fall lt110 mmHg
• Pts without EOD rarely require urgent management
  of HTN and should be referred for outpt
  pharmacotherapy adjustments

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