HYPERTENSIVE CRISIS

DR A.M. ELDEIB COLLEGE OF MEDICINE ALQASSIM UNIVERSITY 2011

what is hypertensive crisis ?

SBP >180 or DBP >120 Urgency = no signs of end-organ damage Days to Weeks Emergency = signs of end-organ damage Minutes to Hrs Need to know pts baseline before crisis

ORGAN AFFECTED
Most Common Clinical Presentations:
Cerebral infarction (24.5%) Pulmonary edema (22.5%) Hypertensive encephalopathy

(16.3%) CHF (12.0%) Intracranial hemorrhage, Aortic dissection Acute renal failure

 Evidence of End-Orgna Damage: Chest pain - Myocardial

ischemia or infarction Back pain - Aortic dissection Dyspnea - Pulmonary edema, congestive heart failure Neurologic symptoms Seizures, altered level of consciousness

NEUROLOGICAL

Cerebral Autoregulation- ??????? Malignant HTN

Retinal

hemorrhages , Papilledem

HTN Encephalopathy

Signs of Cerebral Edema Headache (85%) Nausea and vomiting Weakness and fatigue Change in mental status Blurred vision, Seizures , Focal changes

Cardiac
HTN

affects structure/function of coronary vasculature

Aortic dissection

Acute

HTN

Emergency: LV cant overcome SVR LV failure, Pulmonary Edema or AMI/Arrythmias

Cardiovascular symptoms
Symptoms
Chest

of congestive heart failure (CHF)

pain, dyspnea

Angina Dissecting
back

aneurysm

pain, syncope

 Physical
S3

examination

Cardiovascular

gallop with ralescongestive heart failure Holosystolic murmur dissecting aortic aneurysm Jugular venous distension Peripheral edema

Renal

Acute renal ischemia

Acute

Renal Failure or Oliguria Hematuria Proteinuria

Patient evaluation

Physical Exam

A. Blood Pressure

- Measure in both upper arm and lower extremities,Two measurements 15mins apart B. Optic Fundus Exam hemorrhages, or papilledema C. Neurological Exam for focal and general findings D. Pulmonary Exam for Signs of Pulm Edema E. Cardiovascular S3,S4. Examine all pulses and bruits

BP Goals
No

proven benefit to rapid reduction

induce Ischemia: CVA/MI

can

1-2

hrs: dec MAP by 20-25% or DBP to <120 mmHg 2-6hrs : reduce to <160/110

Treatment

Put pt in a quiet room decrease of 10-20mmHg Acute myocardial ischemia

Nitroglycerin

IV Beta-blockers IV Angiotensin-converting enzyme (ACE) inhibitors IV / sublingual ( captopril, nifidepen)

CHF

with pulmonary edema

IV

Nitroglycerin
Lasix

IV Morphine IV

Oral Drug therapy

Captopril quick acting ACE. 6.25-25 po Q6h. Onset 1530min, duration 4 hs. Nifedipen (break capsules orally )

 Treatment
Cerebral

vascular accident , hypertensive encephalopathy, or subarachnoid hemorrhage)

Nitroprusside Labetalol

IV

IV Nimodipine IV

Treatment
Acute

aortic dissection
IV plus beta-blockers IV

Nitroprusside

Drugs
Nitroprusside Drug of choice for most emergencies. -IV drip 0.25-10 ug/kg/min with immediate onset and cessation of effect within 3-5 min of d/c. Quick on/off

.Drugs - cont

Labetelol
Long

duration of action 3-5hrs, IV boluses or IV drip Drug of choice for cases of increased ICP Contraindicated in Heart failure,

Drugs - cont

Hydralazine 10-20mg Q30min until effect achieved

Onset

10-20min, duration 3-8hrs.

Drugs.

Nitroglycerine
Role

in HTN control after CABG, pulm edema, Myocardial Ischemia Infusion 5-200 ug/min. Immediate onset,

Prognosis

1 yr mortality for untreated HTN Emergency 90% !!! Risk of Coronary, Cerebrovascular or Renal disease cont. Survival improves over time

THANK YOU