management of hypertensive urgencies & emergencies

Management of hypertensive urgencies & emergencies

Emergencies:

BP> 180/120 – impending/ progressive target organ damage

- Immediate reductions required.

Urgencies:

severe elevations in BP without progressive target organ damage

- Severe headache, shortness of breath, epistaxis, severe anxiety

Emergencies:- decrease mean BP by 25%(within minutes to one hour)

- If stable to 160/100-110mmHg – next 2 – 6 hrs.

- Excessive fall!!!

-If stable – normal BP – 24 – 48 hrs

EXCEPTIONS: Patients with ischemic stroke

- Aortic dissection (↓SBP to <100 mmHg)

- Patients in whom BP is lowered to enable use of thrombolytic agents

Oral agents: captopril, labetalol, clonidine

Complications of aggressive management!

Treatment of acute severe hypertension in preeclampsia

Hydralazine ■ 5 mg iv bolus, then 10 mg every 20–30 minutes to a maximum of 25 mg, repeat in several hours as necessary

Labetalol (second-line) ■ 20 mg iv bolus, then 40 mg 10 minutes later, 80 mg every 10 minutes for two additional doses to a maximum of 220 mg

Sodium nitroprusside (rarely, when others fail) ■ 0.25 μg/kg/min to a maximum of 5 μg/kg/min

■ Fetal cyanide poisoning may occur if used for more than4 hours

Treatment of acute severe hypertension in preeclampsia

Nifedipine (controversial) ■ 10 mg po, repeat every 20 minutes to a maximum of 30 mg

■ Caution when using nifedipine with magnesium sulfate, cansee precipitous blood pressure drop

■ Short-acting nifedipine is not approved by the Food and DrugAdministration for managing hypertension

Drug Sodium nitroprusside

Dose 0.25–10 μg/kg/min as IV infusion

Onset of Action Immediate

Duration of Action 1–2 min

Adverse Effects: Nausea, vomiting, muscle twitching, sweating, thiocynate and cyanide intoxication

Special Indications: Most hypertensive emergencies; caution with high intracranial pressure or azotemia

Drug: Nicardipine hydrochloride

Dose: 5–15 mg/h IV

Onset of Action: 5–10 min

Duration of Action: 15-30 min, may exceed 4 hrs

Adverse Effects: Tachycardia, headache, flushing, local phlebitis

Special Indications: Most hypertensive emergencies except acute heart failure; caution with coronary ischemia

Drug: Fenoldopam mesylate

Dose: 0.1–0.3 μg/kg per min IV infusion

Onset of Action: <5 min

Duration of Action: 30 min

Adverse Effects: Tachycardia, headache, nausea, flushing

Special Indications: Most hypertensive emergencies; caution with glaucoma

Drug: Nitroglycerin

Dose: 5–100 μg/min as IV infusion


Duration of Action: 5–10 min

Adverse Effects: Headache, vomiting, methemoglobinemia, tolerance with prolonged use

Special Indications: Coronary ischemia

Drug: Enalaprilat

Dose: 1.25–5 mg every 6 hrs IV


Duration of Action: 6–12 hrs

Adverse Effects: Precipitous fall in pressure in high-renin states; variable response

Special Indications: Acute left ventricular failure; avoid in acute myocardial infarction

Drug: Hydralazine hydrochloride

Dose: 10–20 mg IV 10–40 mg IM

Onset of Action: 10–20 min IV 20–30 min IM

Duration of Action:1–4 hrs IV 4–6 hrs IM

Adverse Effects: Tachycardia, flushing, headache, vomiting,aggravation of angina

Special Indications: Eclampsia

Drug: Labetalol hydrochloride

Dose: 20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion


Duration of Action: 3–6 hrs

Adverse Effects: Vomiting, scalp tingling, bronchoconstriction, dizziness, nausea, heart block, orthostatic hypotension

Special Indications: Most hypertensive emergencies except acute heart failure

Drug: Esmolol hydrochloride

Dose: 250–500 μg/kg/min IV bolus, then 50– 100 μg/kg/min by infusion; may repeat bolus after 5 min or increase infusion to300 μg/min



Adverse Effects: Hypotension, nausea, asthma, first degree heart block, heart failure

Special Indications: Aortic dissection, perioperative

Drug: Phentolamine

Dose: 5–15 mg IV bolus



Adverse Effects: Tachycardia, flushing, headache

Special Indications: Catecholamine excess

management of hypertensive urgencies & emergencies

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