Management of Management of Hypertension and Hypertension and Hypotension in the Hypotension in the Emergency DepartmentEmergency Department

HypertensionHypertension

How do we manage How do we manage Hypertension in the Hypertension in the ER??ER??

Hypertension Hypertension Management in the EDManagement in the ED Annual Census = 78,000 patientsAnnual Census = 78,000 patients Approximately 215 patients per dayApproximately 215 patients per day 40 to 50% have elevated BP 40 to 50% have elevated BP

readings upon admission to the ED readings upon admission to the ED That is roughly 39,000 patients/yr That is roughly 39,000 patients/yr

with elevated blood pressure with elevated blood pressure readings in the ER.readings in the ER.

First Step:First Step:

Categorize Types Categorize Types of of

Hypertension Hypertension

Four Categories of Four Categories of HypertensionHypertension - Hypertensive Emergency- Hypertensive Emergency - Hypertensive Urgency- Hypertensive Urgency - Acute Hypertensive Episode- Acute Hypertensive Episode - Transient Hypertension- Transient Hypertension

What is a What is a Hypertensive Hypertensive

Emergency?Emergency?

Hypertensive Hypertensive EmergencyEmergency - A relative increase in blood pressure - A relative increase in blood pressure

from baseline combined with from baseline combined with Target Target Organ Dysfunction (TOD)Organ Dysfunction (TOD)

- No Defined Pressure MeasurementNo Defined Pressure Measurement- Target Organ Damage is evidentTarget Organ Damage is evident- Also known as Hypertensive Crisis or Also known as Hypertensive Crisis or

Malignant HypertensionMalignant Hypertension- The The MOST MOST Serious form of Serious form of

hypertensionhypertension

How do we define How do we define

Target Organ Target Organ Dysfunction Dysfunction

??????

Target Organ Target Organ DysfunctionDysfunction

Evidence of Damage or Evidence of Damage or Injury to “Target Organs” Injury to “Target Organs” such as the Heart, Brain, such as the Heart, Brain, Lungs, Kidneys, or Aorta.Lungs, Kidneys, or Aorta.

Examples of Target Examples of Target Organ DysfunctionOrgan Dysfunction Acute MI/ Unstable AnginaAcute MI/ Unstable Angina CVACVA ICH / Subarachnoid HemorrhageICH / Subarachnoid Hemorrhage CHFCHF Aortic DissectionAortic Dissection Acute Renal FailureAcute Renal Failure Hypertensive EncephalopathyHypertensive Encephalopathy

How do we determine if How do we determine if

Target Organ DysfunctionTarget Organ Dysfunction

is present? is present?

Evaluation for Target Evaluation for Target Organ DysfunctionOrgan Dysfunction1. 1. EKGEKG: (Evaluation for ST elevation or depression, new T-wave : (Evaluation for ST elevation or depression, new T-wave

inversions, LVH, or new Left BBB)inversions, LVH, or new Left BBB)

2.2. CXRCXR: (CHF/pulmonary edema, cardiomegaly, widened mediastinum): (CHF/pulmonary edema, cardiomegaly, widened mediastinum)

3.3. UA or urine dipUA or urine dip: (looking for proteinuria, red cells, or red cell : (looking for proteinuria, red cells, or red cell casts)casts)

4.4. Chem 8Chem 8: (elevated BUN/CR indicating acute renal insufficiency or : (elevated BUN/CR indicating acute renal insufficiency or failure, look for other etiologies causing mental status changes, like failure, look for other etiologies causing mental status changes, like hypoglycemia)hypoglycemia)

5.5. Neurological ExamNeurological Exam: (Evaluate for lateralizing signs and : (Evaluate for lateralizing signs and symptoms)symptoms)

6.6. Funduscopic ExamFunduscopic Exam: (looking for papilledema or hemorrhages): (looking for papilledema or hemorrhages)

7. 7. CT HeadCT Head: (only if neurological findings are suspicious for acute CVA): (only if neurological findings are suspicious for acute CVA)

Diagnosis and Diagnosis and Management Management

ofof

Hypertensive Hypertensive EmergencyEmergency

Hypertensive Hypertensive EncephalopathyEncephalopathyPathophysiologyPathophysiology: :

- Loss of Cerebral Autoregulation of blood flow - Loss of Cerebral Autoregulation of blood flow resulting in hyperperfusion of the brain, loss resulting in hyperperfusion of the brain, loss of integrity of the blood brain barrier, and of integrity of the blood brain barrier, and vascular necrosis. vascular necrosis.

- Loss of Autoregulation occurs at a constant Loss of Autoregulation occurs at a constant cerebral blood flow of above MAP 150 to 160 cerebral blood flow of above MAP 150 to 160 mmHg. mmHg.

- Acute OnsetAcute Onset- ReversibleReversible

Hypertensive Hypertensive EncephalopathyEncephalopathySymptomsSymptoms: : Headache, Nausea/Vomiting, Lethargy,Headache, Nausea/Vomiting, Lethargy, Confusion, Lateralizing neurological symptomsConfusion, Lateralizing neurological symptoms that are not often in an anatomical that are not often in an anatomical

distribution. distribution.

SignsSigns: : Papilledema, Retinal HemorrhagesPapilledema, Retinal Hemorrhages Decreased level of consciousness, ComaDecreased level of consciousness, Coma Focal neurological findingsFocal neurological findings

Management of Management of Hypertensive Hypertensive EncephalopathyEncephalopathy

Reduce Mean Arterial Pressure (MAP) by 20 Reduce Mean Arterial Pressure (MAP) by 20 to 25% (T.397) and do not exceed this within to 25% (T.397) and do not exceed this within first 30 to 60 min.first 30 to 60 min.

Rosen recommends reduction of 30 to 40% Rosen recommends reduction of 30 to 40% (R.1759)(R.1759)

MAP= 1/3(SBP-DBP) + DBPMAP= 1/3(SBP-DBP) + DBP Treatment Reduces vasospasm that occurs at Treatment Reduces vasospasm that occurs at

these high pressuresthese high pressures Avoid excessive BP reduction to prevent Avoid excessive BP reduction to prevent

hypoperfusion of the brain and further hypoperfusion of the brain and further cerebral ischemiacerebral ischemia

Management of Management of Hypertensive Hypertensive EncephalopathyEncephalopathy

- - Nitroprusside Nitroprusside is the agent of is the agent of choice (T.397) and (R.1759)choice (T.397) and (R.1759)

- Nitroglycerin and Labetalol have - Nitroglycerin and Labetalol have been used successfully, but been used successfully, but have not replaced Nitroprussidehave not replaced Nitroprusside

Management of Management of Ischemic Ischemic

CVACVA

Ischemic CVAIschemic CVA

PathophysiologyPathophysiology: :

Elevated Blood Pressure can be Elevated Blood Pressure can be the cause of the central nervous the cause of the central nervous system event, OR, it may be a system event, OR, it may be a normal physiologic response normal physiologic response (Cushing’s Reflex)(Cushing’s Reflex)

Ischemic CVA Ischemic CVA ManagementManagement Elevated blood pressure is usually a Elevated blood pressure is usually a

physiologic response to the stroke itself physiologic response to the stroke itself and and NOTNOT the immediate cause the immediate cause

This elevation of blood pressure This elevation of blood pressure maintains cerebral perfusion to viable but maintains cerebral perfusion to viable but edematous tissue surrounding the edematous tissue surrounding the ischemic area.ischemic area.

Most embolic or thrombotic strokes do Most embolic or thrombotic strokes do NOTNOT have substantial BP elevations and have substantial BP elevations and do not need aggressive therapydo not need aggressive therapy

Ischemic CVA Ischemic CVA ManagementManagement

ManagementManagement: VERY CONTROVERSIAL!: VERY CONTROVERSIAL!

Recent Trends leans towards Recent Trends leans towards NOT NOT treating hypertension in the presence treating hypertension in the presence of a Cerebrovascular Accident of a Cerebrovascular Accident (thrombotic or embolic) unless (thrombotic or embolic) unless Diastolic Blood Pressure exceeds Diastolic Blood Pressure exceeds 140mmHg.140mmHg.

Ischemic CVA Ischemic CVA ManagementManagement

TintinelliTintinelli: Favors lowering MAP : Favors lowering MAP (mean arterial pressure) by 20%. (mean arterial pressure) by 20%.

Recommends IV Labetalol in small Recommends IV Labetalol in small doses of 5mg increments doses of 5mg increments IFIF Diastolic Blood Pressure is higher Diastolic Blood Pressure is higher than 140 mmHg.than 140 mmHg.

(T. 398)(T. 398)

Ischemic CVA Ischemic CVA ManagmentManagment

RosenRosen: In most cases, recommends : In most cases, recommends no treatment of Hypertension in no treatment of Hypertension in CVA patients. CVA patients.

(p. 1760). (p. 1760). - However, the author does - However, the author does

recommend treating HTN if recommend treating HTN if diastolic blood pressure is greater diastolic blood pressure is greater than 140 mmHg. than 140 mmHg.

Management of Management of

Hemorrhagic CVAHemorrhagic CVA

Causes of Hemorrhagic Causes of Hemorrhagic CVA CVA Hypertensive Vascular DiseaseHypertensive Vascular Disease Arteriovenous Anomalies Arteriovenous Anomalies

(AVM)(AVM) Arterial AneurysmsArterial Aneurysms TumorsTumors TraumaTrauma

Hemorrhagic CVA Hemorrhagic CVA ManagementManagement

Hypertension associated Hypertension associated with hemorrhagic stroke is with hemorrhagic stroke is usually transitory and the usually transitory and the result of increased result of increased intracranial pressure and intracranial pressure and irritation of the Autonomic irritation of the Autonomic Nervous SystemNervous System

Hemorrhagic CVA Hemorrhagic CVA ManagementManagement Hemorrhagic CVA’s commonly results Hemorrhagic CVA’s commonly results

in a profound reactive rise in blood in a profound reactive rise in blood pressurepressure

Management is CONTROVERSIAL.Management is CONTROVERSIAL. Subarachnoid Hemorrhage: oral Subarachnoid Hemorrhage: oral

nimodipine (nimotop) 60mg po q 4 nimodipine (nimotop) 60mg po q 4 hours to reverse vasospasm. (T.398)hours to reverse vasospasm. (T.398)

Nicardipine: 2mg IV boluses followed Nicardipine: 2mg IV boluses followed by an IV infusion of 4 to 15 mg/hr is by an IV infusion of 4 to 15 mg/hr is used by some to treat Subarachnoid used by some to treat Subarachnoid Hemorrhage. (T.398)Hemorrhage. (T.398)

Management of Management of CHF/CHF/

Pulmonary Pulmonary EdemaEdema

Congestive Heart Congestive Heart Failure / Pulmonary Failure / Pulmonary EdemaEdema

PathophysiologyPathophysiology: :

Increased Afterload Increased Afterload with decreased Cardiac with decreased Cardiac OutputOutput

CHF / Pulmonary CHF / Pulmonary EdemaEdema

SymptomsSymptoms:: Shortness of Breath, Cough, Chest PainShortness of Breath, Cough, Chest Pain

Lower Extremity SwellingLower Extremity Swelling

SignsSigns:: Jugular Venous Distension, Rales, S3 Jugular Venous Distension, Rales, S3

GallopGallop Hepatomegaly, Pedal EdemaHepatomegaly, Pedal Edema

CHF / Pulmonary CHF / Pulmonary Edema Management in Edema Management in the EDthe ED

- Nitroprusside or IV Nitroglycerin (T. Nitroprusside or IV Nitroglycerin (T. 398)398)

- Rosen: May start with Nitroglycerin, Rosen: May start with Nitroglycerin, but Nitroprusside is agent of choice if but Nitroprusside is agent of choice if Pulmonary Edema is present. (R. 1760)Pulmonary Edema is present. (R. 1760)

- Attempt treatment of CHF initially with Attempt treatment of CHF initially with standard agents (Lasix,sublingual NTG, standard agents (Lasix,sublingual NTG, morphine), as these often lower blood morphine), as these often lower blood pressure, but resort to Nitroprusside if pressure, but resort to Nitroprusside if necessary (R. 1761)necessary (R. 1761)

Management of Management of AcuteAcute

Coronary Syndrome/Coronary Syndrome/

Acute MIAcute MI

Acute Coronary Acute Coronary Syndrome /Syndrome / Acute MI Acute MIPathophysiologyPathophysiology::

- - IncreasedIncreased afterload, afterload, cardiac workload, and cardiac workload, and myocardial oxygen demandmyocardial oxygen demand

- - DecreasedDecreased coronary coronary artery blood flowartery blood flow

Acute Coronary Acute Coronary Syndrome / Syndrome / Acute MIAcute MISymptomsSymptoms:: Chest Pain, Nausea / Vomiting, Diaphoresis,Chest Pain, Nausea / Vomiting, Diaphoresis, Shortness of BreathShortness of Breath

SignsSigns: : Congestive Heart Failure Signs, Congestive Heart Failure Signs, S4 GallopS4 Gallop (due to decreased ventricular compliance)(due to decreased ventricular compliance) Few physical findings in many patientsFew physical findings in many patients Clinical History is very ImportantClinical History is very Important

Acute Coronary Acute Coronary Syndrome/Syndrome/Acute MIAcute MI- Immediate Blood Pressure Immediate Blood Pressure

reduction is reduction is indicatedindicated to to prevent Myocardial Damageprevent Myocardial Damage

- No specific Defined BP targetNo specific Defined BP target- Tailor treatment to symptom Tailor treatment to symptom

reliefrelief (T. 398)(T. 398)

Acute Coronary Acute Coronary Syndrome / Syndrome / Acute MIAcute MI

ManagementManagement: : Nitroglycerin IV or Sublingual (T. 398)Nitroglycerin IV or Sublingual (T. 398) Nitroprusside (T. 398)Nitroprusside (T. 398) Beta Blockers (Esmolol,Lopressor) (T. Beta Blockers (Esmolol,Lopressor) (T.

356-357)356-357)

Nitroglycerin is Drug of Choice (R. Nitroglycerin is Drug of Choice (R. 1761)1761)

Dissection of Dissection of

Thoracic AortaThoracic Aorta

Dissection of Thoracic Dissection of Thoracic AortaAorta

Pathophysiology:Pathophysiology:

- Atherosclerotic Vascular Disease, - Atherosclerotic Vascular Disease, Chronic Hypertension, increased Chronic Hypertension, increased shearing force on the thoracic aorta, shearing force on the thoracic aorta, leading to intimal tear.leading to intimal tear.

- 50% begin in ascending aorta- 50% begin in ascending aorta

- 30% at aortic arch- 30% at aortic arch

- 20% in descending aorta (R.1762-3)- 20% in descending aorta (R.1762-3)

Dissection of Thoracic Dissection of Thoracic AortaAorta SymptomsSymptoms::- Chest pain radiating to the back (classic presentation)Chest pain radiating to the back (classic presentation)- Neurological Symptoms (carotid artery dissection)Neurological Symptoms (carotid artery dissection)- Angina (coronary artery dissection)Angina (coronary artery dissection)- Shortness of breath (aortic insufficiency, cardiac Shortness of breath (aortic insufficiency, cardiac

tamponade)tamponade)

SignsSigns::- Differential Blood Pressure (in UE)- Differential Blood Pressure (in UE)- Bruit (interscapular)Bruit (interscapular)- Neurological DeficitsNeurological Deficits- Acute Cardiac Tamponade (rare)Acute Cardiac Tamponade (rare)

Dissection of Thoracic Dissection of Thoracic AortaAortaManagementManagement: :

- Medications with negative inotropic Medications with negative inotropic effects (beta-blockers) effects (beta-blockers) MUSTMUST be given be given FIRSTFIRST. (reduces shearing force). (reduces shearing force)

- Vasodilators (nitroprusside) may be Vasodilators (nitroprusside) may be added for further antihypertensive added for further antihypertensive treatment after administration of a treatment after administration of a negative inotropic agent.negative inotropic agent.

Dissection of Thoracic Dissection of Thoracic AortaAorta

Optimal Blood Pressure in Optimal Blood Pressure in these patients is undefined these patients is undefined and must be tailored for each and must be tailored for each patient, however,patient, however,

SBP of 120-130mmHg may be SBP of 120-130mmHg may be a intial starting point. (T.408)a intial starting point. (T.408)

Acute Renal Acute Renal FailureFailure

Acute Renal FailureAcute Renal Failure

PathophysiologyPathophysiology::

- Hypertensive Glomerulonephropathy, Hypertensive Glomerulonephropathy, Acute Tubular Necrosis (ATN)Acute Tubular Necrosis (ATN)

- Worsening renal function in the setting - Worsening renal function in the setting of severe hypertension with elevation of severe hypertension with elevation of BUN/CR, proteinuria, or the of BUN/CR, proteinuria, or the presence of red cells and red cell casts presence of red cells and red cell casts in the urine.in the urine.

Acute Renal FailureAcute Renal Failure

SymptomsSymptoms::- Many times there are few actual - Many times there are few actual

symptomssymptoms- Facial or Peripheral Edema due to fluid Facial or Peripheral Edema due to fluid

overload or proteinuria may be overload or proteinuria may be present, shortness of breathpresent, shortness of breath

SignsSigns: : - Few findings unless edematousFew findings unless edematous- Pulmonary EdemaPulmonary Edema

Acute Renal FailureAcute Renal Failure

ManagementManagement::

- Nitroprusside is agent of choice (T.398)Nitroprusside is agent of choice (T.398)- Dialysis (as needed)Dialysis (as needed)- Rosen: Lasix to enhance Sodium Rosen: Lasix to enhance Sodium

excretion; Also recommends excretion; Also recommends Nitroprusside or Nifedipine (R.1761)Nitroprusside or Nifedipine (R.1761)

- Nitroglycerin is also a good agent in Nitroglycerin is also a good agent in this setting since it is hepatically this setting since it is hepatically metabolized and gastrointestinally metabolized and gastrointestinally excreted.excreted.

PheochromocytoPheochromocytomama

PheochromocytomaPheochromocytoma

PathophysiologyPathophysiology::

- Alpha and Beta stimulation of the - Alpha and Beta stimulation of the cardiovascular system due to cardiovascular system due to adrenergic excess statesadrenergic excess states

PheochromocytomaPheochromocytoma

SymptomsSymptoms: :

Episodic Headaches, flushing, tremor, Episodic Headaches, flushing, tremor, diaphoresis, diarrhea, hyperactivity, diaphoresis, diarrhea, hyperactivity, and palpitationsand palpitations

SignsSigns::

Tachycardia, tachypnea, tremor, Tachycardia, tachypnea, tremor, hyperdynamic state (high output CHF) hyperdynamic state (high output CHF)

PheochromocytomaPheochromocytoma

ManagementManagement: :

- Alpha Blocker Alpha Blocker FIRSTFIRST, followed by a , followed by a Beta BlockerBeta Blocker

- Phentolamine (alpha) + Esmolol Phentolamine (alpha) + Esmolol (beta)(beta)

- Labetalol IV (combined alpha and Labetalol IV (combined alpha and beta blockade)beta blockade)

Toxemia of Toxemia of PregnancyPregnancy

Eclampsia/Pre-Eclampsia/Pre-EclampsiaEclampsia

Toxemia of PregnancyToxemia of Pregnancy

PathophysiologyPathophysiology::

- Systemic arterial vasoconstriction Systemic arterial vasoconstriction (including placental, leading to (including placental, leading to decreased uterine blood flow).decreased uterine blood flow).

- Defined as SBP = 140/90 mmHg or Defined as SBP = 140/90 mmHg or greater, greater, OROR a 20 mmHg rise in SBP or a 20 mmHg rise in SBP or 10 mmHg rise in DBP from baseline 10 mmHg rise in DBP from baseline and evidence of HELLP Syndromeand evidence of HELLP Syndrome

Toxemia of PregnancyToxemia of Pregnancy

SymptomsSymptoms::

Lower extremity swelling, headache, Lower extremity swelling, headache, confusion, seizures, comaconfusion, seizures, coma

SignsSigns::

Edema, hyperreflexia, elevation of blood Edema, hyperreflexia, elevation of blood pressure related to baseline BP prior to pressure related to baseline BP prior to pregnancy (elevation may be mild pregnancy (elevation may be mild 125/75)125/75)

Toxemia of PregnancyToxemia of Pregnancy

ManagementManagement: :

- IV Magnesium Sulfate, Hydralazine.IV Magnesium Sulfate, Hydralazine.- May also use nifedipine or labetalol May also use nifedipine or labetalol

(R.1762)(R.1762)- Delivery of Fetus is definitive Delivery of Fetus is definitive

treatment of pre-eclampsiatreatment of pre-eclampsia

Summary of Medications Summary of Medications used for Hypertensive used for Hypertensive EmergenciesEmergencies- - Intravenous NitroglycerinIntravenous Nitroglycerin:: Start at 0.2 to 0.4 mcg/kg/min (10 to 30 mcg/min) and Start at 0.2 to 0.4 mcg/kg/min (10 to 30 mcg/min) and

rapidly increase in 5 to10 mcg/min increments. Titrate to BP rapidly increase in 5 to10 mcg/min increments. Titrate to BP and symptomatic improvement. (T.369)and symptomatic improvement. (T.369)

- - NitroprussideNitroprusside: : Start 0.3 mcg/kg/min and titrate up every 5 to 10 minutes Start 0.3 mcg/kg/min and titrate up every 5 to 10 minutes

based on BP and clinical response. (T.369)based on BP and clinical response. (T.369)

- - EsmololEsmolol: 500 mcg/kg initial bolus over 1 minute, then start : 500 mcg/kg initial bolus over 1 minute, then start infusion at 50 to 150 mcg/kg/min (T.408)infusion at 50 to 150 mcg/kg/min (T.408)

- - Metoprolol (LopressorMetoprolol (Lopressor): 5mg IV every 2 minutes for a total of ): 5mg IV every 2 minutes for a total of 3 doses, then start infusion at 2 to 5 mg/hr. (T.408)3 doses, then start infusion at 2 to 5 mg/hr. (T.408)

Summary of Medications Summary of Medications used for Hypertensive used for Hypertensive EmergenciesEmergencies

- - LabetalolLabetalol: 20mg IV initial dose, with repeat doses of : 20mg IV initial dose, with repeat doses of 40mg to 80mg every 10 minutes to reach desired 40mg to 80mg every 10 minutes to reach desired effect or max dose 300mg. (T. 408)effect or max dose 300mg. (T. 408)

- NicardipineNicardipine: 2mg IV boluses followed by an IV infusion : 2mg IV boluses followed by an IV infusion of 4 to 15 mg/hrof 4 to 15 mg/hr

- Magnesium Sulfate IVMagnesium Sulfate IV: 4 to 6 grams over 15 minutes, : 4 to 6 grams over 15 minutes, followed by IV infusion of 1 to 2 grams/hour followed by IV infusion of 1 to 2 grams/hour

- HydralazineHydralazine: 10 to 20mg IV: 10 to 20mg IV

What is a What is a Hypertensive Hypertensive

Urgency??Urgency??

Hypertensive Hypertensive UrgencyUrgency - A relative increase in blood - A relative increase in blood

pressure from baseline pressure from baseline WITHOUTWITHOUT current evidence of TOD, but current evidence of TOD, but potential of progression to TOD is potential of progression to TOD is HIGHHIGH..

- Increased likelihood when pre-- Increased likelihood when pre-existing conditions are presentexisting conditions are present

(renal insufficiency, CAD, CHF)(renal insufficiency, CAD, CHF)

Hypertensive UrgencyHypertensive Urgency

- Current recommendation is the gradual Current recommendation is the gradual reduction of blood pressure within 24 to reduction of blood pressure within 24 to 48 hours by using oral antihypertensive 48 hours by using oral antihypertensive agentsagents

- Non-compliance is a common cause, Non-compliance is a common cause, therefore, restarting a current regimen of therefore, restarting a current regimen of blood pressure medication is appropriateblood pressure medication is appropriate

- Making needed changes to current blood Making needed changes to current blood pressure medication regimens is also pressure medication regimens is also appropriateappropriate

- Follow-up within 24 hours should be Follow-up within 24 hours should be arranged with Primary Care Physicianarranged with Primary Care Physician

Oral Regimens for Oral Regimens for Treatment of Treatment of Hypertensive Hypertensive Urgency in the ED Urgency in the ED (Tintinelli pg. 402)(Tintinelli pg. 402)

- ClonidineClonidine: 0.1 to 0.2mg PO, repeat : 0.1 to 0.2mg PO, repeat 0.1mg q hour to desired BP reduction 0.1mg q hour to desired BP reduction or max of 0.7mg.or max of 0.7mg.

- LabetalolLabetalol: 200 to 400mg PO, repeat : 200 to 400mg PO, repeat every 2 to 3 hoursevery 2 to 3 hours

- CaptoprilCaptopril: 25mg PO: 25mg PO- Losartan: 50mg POLosartan: 50mg PO

What is an Acute What is an Acute

Hypertensive Episode?Hypertensive Episode?

Acute Hypertensive Acute Hypertensive EpisodeEpisode

Elevation of Blood Pressure Elevation of Blood Pressure relative to baseline, but relative to baseline, but WITHOUT WITHOUT evidence of acute evidence of acute OR OR impending Target Organ impending Target Organ Dysfunction (TOD)Dysfunction (TOD)

Management of Acute Management of Acute Hypertensive EpisodeHypertensive Episode- Paucity of evidence that acute intervention in ED Paucity of evidence that acute intervention in ED

is warranted for Hypertensive Episodeis warranted for Hypertensive Episode- Complications can occur in acute treatment of Complications can occur in acute treatment of

patients with chronically elevated blood pressure patients with chronically elevated blood pressure - If HTN is newly diagnosed in the ER, patients If HTN is newly diagnosed in the ER, patients

should be referred to Primary Care physician for should be referred to Primary Care physician for evaluation and initiation of therapy within 24 to evaluation and initiation of therapy within 24 to 48 hours48 hours

- Again, restarting prior blood pressure medication Again, restarting prior blood pressure medication regimens or adjusting doses is appropriate for regimens or adjusting doses is appropriate for patients with previously diagnosed hypertension.patients with previously diagnosed hypertension.

What is Transient What is Transient

Hypertension??Hypertension??

Treatment of Transient Treatment of Transient HypertensionHypertension- Transient HTN occurs in association with Transient HTN occurs in association with

other conditions like anxiety, alcohol other conditions like anxiety, alcohol withdrawal syndromes, toxicological withdrawal syndromes, toxicological substances, and sudden cessation of substances, and sudden cessation of medications)medications)

- Treatment is aimed at underlying causeTreatment is aimed at underlying cause- ““White-Coat Hypertension”White-Coat Hypertension”- Single encounter in ED does not warrant Single encounter in ED does not warrant

diagnosis of HTN or treatment of HTNdiagnosis of HTN or treatment of HTN- Follow-up with Primary Care PhysicianFollow-up with Primary Care Physician

SWITCHING SWITCHING GEARSGEARS

Hypotension/ShockHypotension/Shock

Management in the EDManagement in the ED

Hypotension/ShockHypotension/Shock

Types of ShockTypes of Shock::

-- Hypovolemic Hypovolemic (inadequate circulating volume)(inadequate circulating volume) - Cardiogenic - Cardiogenic (inadequate pump function)(inadequate pump function) - Distributive - Distributive (peripheral vasodilitation)(peripheral vasodilitation) - Obstructive- Obstructive (extra-cardiac obstruction of blood (extra-cardiac obstruction of blood flow)flow)

Hypotension/Shock Hypotension/Shock Goals of Management Goals of Management

1. Determine Cause1. Determine Cause:: - Usually very apparent- Usually very apparent

- Can be subtle- Can be subtle

- No single Vital Sign that is - No single Vital Sign that is diagnostic of Shockdiagnostic of Shock

- Initial Therapy guided by clinical - Initial Therapy guided by clinical findingsfindings

Management of Management of Hypotension/ShockHypotension/Shock

2. Evaluate Signs and 2. Evaluate Signs and Symptoms:Symptoms:

- Tachycardia- Tachycardia

- Decreased Urine Output- Decreased Urine Output

- Cool, Mottled Skin- Cool, Mottled Skin

- Cyanosis- Cyanosis

- Confusion- Confusion

Hypotension/Shock Hypotension/Shock Goals of ResuscitationGoals of Resuscitation

ABC’sABC’s:: A- Secure Airway (intubate if A- Secure Airway (intubate if

needed)needed)

B- Insure oxygenation and B- Insure oxygenation and ventillationventillation

C- Provide Hemodynamic C- Provide Hemodynamic Stabilization (correction of Stabilization (correction of hypotension based on etiology)hypotension based on etiology)

ResuscitationResuscitation

Initiate Fluid TherapyInitiate Fluid Therapy::0.25 to 0.5 Liters of Normal 0.25 to 0.5 Liters of Normal

Saline (NS) or similar Saline (NS) or similar isotonic crystalloid should isotonic crystalloid should be administered every 5 to be administered every 5 to 10 minutes as needed for 10 minutes as needed for correction of hypotensioncorrection of hypotension

Rapid Fluid Rapid Fluid AdministrationAdministration

It is not unusual for a It is not unusual for a patient to require 4 to 6 patient to require 4 to 6 Liters of fluid in the initial Liters of fluid in the initial phase of resuscitation.phase of resuscitation.

Goal of Fluid Goal of Fluid ResusciationResusciation

- Stabilization of pt’s mentationStabilization of pt’s mentation- Improvement in Blood PressureImprovement in Blood Pressure- Reduction of Pulse RateReduction of Pulse Rate- Improved Skin PerfusionImproved Skin Perfusion- Urine Output > 30ml per hourUrine Output > 30ml per hour

Inotropic SupportInotropic Support

If If NONO response to initial fluid response to initial fluid infusion of 3 to 4 L is noted, infusion of 3 to 4 L is noted, OROR if if there are signs of fluid overload there are signs of fluid overload (pulmonary edema), Inotropic (pulmonary edema), Inotropic agents should be started.agents should be started.

Inotropic AgentsInotropic Agents

- DopamineDopamine: Start infusion at 5 : Start infusion at 5 mcg/kg/min and titrate up to 20 mcg/kg/min and titrate up to 20 mcg/kg/min in order to achieve mcg/kg/min in order to achieve desired BPdesired BP

- Indicated for reversing hypotension Indicated for reversing hypotension related to AMI, trauma, sepsis, heart related to AMI, trauma, sepsis, heart failure, and renal failure when fluid failure, and renal failure when fluid resuscitation is unsuccessful or not resuscitation is unsuccessful or not appropriate (T. 212)appropriate (T. 212)

Inotropic AgentsInotropic Agents

- DobutamineDobutamine: Dosage range is 2 to 20 : Dosage range is 2 to 20 mcg/kg/min, however, most patients can mcg/kg/min, however, most patients can be maintained at a rate of 10 be maintained at a rate of 10 mcg/kg/minmcg/kg/min

- Indicated for cardiovascular Indicated for cardiovascular decompensation due to ventricular decompensation due to ventricular dysfunction or low-output heart failuredysfunction or low-output heart failure

- Agent of choice for management of Agent of choice for management of Cardiogenic ShockCardiogenic Shock

- Less effect on Heart Rate than DopamineLess effect on Heart Rate than Dopamine (T. 212)(T. 212)

Inotropic AgentsInotropic Agents

- Norepinephrine (Levophed)Norepinephrine (Levophed): start infusion at 2 : start infusion at 2 mcg/min and titrate to achieve desired blood mcg/min and titrate to achieve desired blood pressure.pressure.

- Used when there is inadequate response to Used when there is inadequate response to other pressors. other pressors.

- Lowest dosage that maintains BP should be Lowest dosage that maintains BP should be used in order to minimize the complications of used in order to minimize the complications of vasoconstrictionvasoconstriction

- Increased survival rates of up to 40% in septic Increased survival rates of up to 40% in septic shock have been reported in the literatureshock have been reported in the literature

(T. 246)(T. 246)

End Point of End Point of ResuscitationResuscitation

- Normalization of blood pressure, Normalization of blood pressure, heart rate, and urine outputheart rate, and urine output

- Goal is to maximize survival and Goal is to maximize survival and minimize morbidity using objective minimize morbidity using objective hemodynamic and physiologic hemodynamic and physiologic values to guide therapyvalues to guide therapy

Questions ???Questions ???