{"id":5105,"date":"2011-07-14T20:23:28","date_gmt":"2011-07-14T20:23:28","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5105.htm\/"},"modified":"2011-09-26T22:53:41","modified_gmt":"2011-09-26T22:53:41","slug":"hypertension-2","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/medical-surgical\/hypertension-2.htm\/","title":{"rendered":"Hypertension"},"content":{"rendered":"<h2><span class=\"ez-toc-section\" id=\"Systemic_Hypertension\"><\/span>Systemic Hypertension<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>Three categories of ED presentations (Annals 41:1, April 2003; excellent review article):<\/p>\n<ul>\n<li>Severely Increased BP:\u00a0 no treatment, f\/u within a week<\/li>\n<li>Hypertensive Urgency:\u00a0 Increased BP (DBP &gt;115 to 120 mm Hg) with evidence of prior, but not active end organ damage.\u00a0 Examples are a patient with a history of MI or CVA<\/li>\n<li>Hypertensive Emergency:\u00a0 Increased BP with signs of acute end organ damage<\/li>\n<\/ul>\n<p><a href=\"\/wp-content\/images\/part1\/mem03114002.jpg\"> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/mem03114002_small.jpg\" alt=\"\" \/><\/a><\/p>\n<h4>Clinical Examination<\/h4>\n<p>Take BP in both arms, and before and after evaluation to get true reading<\/p>\n<p>Examine fundi for retinal hemorrhage and papilledema<\/p>\n<p>Signs of Heart Failure<\/p>\n<p>Creatinine and UA for protein and blood.\u00a0 Urine dipstick totally normal rules out clinically\u00a0 significant creatnine elevation\u00a0 (AEM 2002 9:1)\u00a0 Signs of acute damage are large numbers of red cells and red cell casts<\/p>\n<p>EKG<\/p>\n<h4>Drugs for HTN Emergency<\/h4>\n<p>nitroprusside is the traditional first choice (beware in renal failure), but labetalol is quickly becoming a more attractive option.\u00a0 Aim to reduce MAP by 30-40% over the first two hours.<\/p>\n<p><strong>Drug<\/strong> <strong>Dose*<\/strong> <strong>Onset of Action<\/strong> <strong>Duration of Action<\/strong> <strong>Adverse Effects\u0086<\/strong> <strong>Special Indications<\/strong> <strong>Vasodilators<\/strong> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> Sodium nitroprusside 0.25-10 \u00b5g\/kg per min as IV infusion\u0087 (maximal dose for 10 min only) Immediate Nausea, vomiting, muscle twitching, sweating, thiocyanate and cyanide intoxication Most hypertensive emergencies; caution with high intracranial pressure or azotemia Nicardipine hydrochloride 5-15 mg\/h IV 5-10 min 1-4 h Tachycardia, headache, flushing, local phlebitis Most hypertensive emergencies except acute heart failure; caution with coronary ischemia Fenoldopam mesylate 0.1-0.3 \u00b5g\/kg per min IV infusion &lt;5 min 30 min Tachycardia, headache, nausea, flushing Most hypertensive emergencies; caution with glaucoma Nitroglycerin 5-100 \u00b5g\/min IV infusion\u0087 2-5 min 3-5 min Headache, vomiting, methemoglobinemia, tolerance with prolonged use Coronary ischemia Enalaprilat 1.25-5 mg every 6 h IV 15-30 min 6 h Precipitous decrease in pressure in high-renin states; response variable Acute left ventricular failure; avoid in acute myocardial infarction Hydralazine hydrochloride 10-20 mg IV; 10-50 mg IM 10-20 min; 20-30 min 3-8 h Tachycardia, flushing, headache, vomiting, aggravation of angina Eclampsia Diazoxide 50-100 mg IV bolus repeated or 15-30 mg\/min infusion 2-4 min 6-12 h Nausea, flushing, tachycardia, chest pain Now obsolete: when no intensive monitoring available <strong>Adrenergic inhibitors<\/strong> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/pixel.gif\" alt=\"\" \/> Labetalol hydrochloride 20-80 mg IV bolus every 10 min; 0.5-2.0 mg\/min IV infusion 5-10 min 3-6 h Vomiting, scalp tingling, burning in throat, dizziness, nausea, heart block, orthostatic hypotension Most hypertensive emergencies except acute heart failure Esmolol hydrochloride 250-500 \u00b5g\/kg per min for 1 min, then 50-100 \u00b5g\/kg per min for 4 min; may repeat sequence 1-2 min 10-20 min Hypotension, nausea Aortic dissection, perioperative Phentolamine 5-15 mg IV 1-2 min 3-10 min Tachycardia, flushing, headache Catecholamine excess From the National High Blood Pressure Education Program<strong>IV,<\/strong> Intravenous; <strong>IM,<\/strong> intramuscular. <a>*These doses might vary from those in the <em> Physicians&#8217; Desk Reference,<\/em> 51st ed. <\/a><a>\u0086Hypotension can occur with all agents. <\/a><a>\u0087Requires special delivery system.<\/a><\/p>\n<h4>Cerebrovascular Emergencies<\/h4>\n<p>Autoregulation of cerebral blood flow is altered in patients with hypertension particularly in the setting of underlying cerebrovascular disease such that even slight decreases in blood pressure increase the risk of a cerebral ischemic event. The National Institute of Neurologic Disorders and Stroke (NINDS) recommends deferral of treatment of systolic pressures of 185-220mm Hg and\/or diastolic pressures of 105-120mm Hg in the absence of other clear indications for immediate intervention.\u00a0 (J Emerg Med 19(4):339, 2000)<\/p>\n<p>AHA recommendations for hemorrhagic stroke is to treat MAP&gt;130 or SBP&gt; 220.\u00a0 Nimodipine is to prevent vasospasm not to treat the BP.<\/p>\n<h4>Accelerated-Malignant Hypertension<\/h4>\n<p>Most commonly occurs in young black males with renal parenchymal disease or renovascular disease.\u00a0 Ocular findings will be present on fundoscopic exam.\u00a0 Papilledema is the sine qua non of malignant hypertension.\u00a0 If it is absent, then it is accelerated hypertension, but the prognosis is just as bad.\u00a0 Treatment should begin immediately.<\/p>\n<h4>Hypertensive Encephalopathy<\/h4>\n<p>Triad of htn, altered mental status and papilledema (often) heralds this condition.\u00a0 This state is most likely to occur in previously normotensive patients whose cerebral autoregulatory system is not prepared for the precipitous rise in BP.\u00a0 A CT scan will show characteristic changes.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"Secondary_Hypertension\"><\/span>Secondary Hypertension<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<h4>Acute Renal Disease<\/h4>\n<p>Renal Artery Stenosis-young white women get medial fibroplasia of renal arteries.\u00a0 Can also be seen in blacks and whites often with rapidly progressive disease.\u00a0 ACEI may cause improvement with unilateral stenosis, but failure in bilat.<\/p>\n<p>Glomerulonephritis-IgA (#1 cause), post-Strep, Henoch-Schoenlein Purpura<\/p>\n<h4>Scleroderma-Induced Renovascular Hypertension<\/h4>\n<p>will have elevated renin<\/p>\n<p>need to give high dose ACEIs<\/p>\n<h4>Preeclampsia<\/h4>\n<p>From 20 weeks gestation till 2 weeks postpartum<\/p>\n<h4>Toxicologic Ingestions<\/h4>\n<p>sympathomimetics, MAO interactions<\/p>\n<h4>Coarctation of the Aorta<\/h4>\n<h4>Pheochromocytoma<\/h4>\n<p>Tachy, HA, hypertension, check urine metanephrine, serum catecholamines<\/p>\n<p>Give IV phentolamine<\/p>\n<p>&nbsp;<\/p>\n<p>Test performance characteristics\u00a0\u0097\u00a0Data comparing the test performance characteristics of plasma fractionated metanephrines and 24-hour urinary fractionated metanephrines and catecholamine measurements are described here:<\/p>\n<p>In one multicenter cohort study that included 214 patients with confirmed pheochromocytoma and 644 patients who were determined not to have the tumor, (both groups being tested for either sporadic or familial pheochromocytoma), the following characteristics for a number of biochemical tests were reported [<a href=\"http:\/\/utdol.com\/online\/content\/abstract.do?topicKey=adrenal\/14066&amp;refNum=30\">30<\/a>] :<\/p>\n<ul>\n<li>Sensitivity was highest for plasma fractionated metanephrines (99 percent) followed by urinary fractionated metanephrines (97 percent), urinary catecholamines (86 percent), plasma catecholamines (84 percent), urinary total metanephrines (77 percent), and urinary vanillylmandelic acid (64 percent).<\/li>\n<\/ul>\n<ul>\n<li>Specificity was highest for urinary vanillylmandelic acid (95 percent) followed by urinary total metanephrines (93 percent), plasma fractionated metanephrines (89 percent), urinary catecholamines (88 percent), plasma catecholamines (81 percent), and lowest for urinary fractionated metanephrines (69 percent).<\/li>\n<\/ul>\n<ul>\n<li>Using receiver operating characteristic curves, sensitivity and specificity values at different upper reference limits were highest for plasma fractionated metanephrines.<\/li>\n<\/ul>\n<p>(from uptodate 2008)<\/p>\n<h4>Hyperaldosteronism<\/h4>\n<p>Draw tube for renin and aldosterone<\/p>\n<h4>Withdrawal<\/h4>\n<h3><span class=\"ez-toc-section\" id=\"Outpatient_Treatment\"><\/span>Outpatient Treatment<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>NIH&#8217;s ALLHAT study shows equal effectiveness between thiazide diuretic (chlorthalidone), lisinopril, and amlodipine for the prevention of MIs and coronary death.\u00a0 The diuretic was more effective at preventing heart failure and more effective than amlodipine at preventing stroke.\u00a0 The ALLHAT study included more minorities than a recent Australian study which showed ACEI are better.\u00a0 Probably the best choice is an ACEI and a diuretic for double therapy in all comers.<\/p>\n<p>&nbsp;<\/p>\n<p>|\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[8],"tags":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Hypertension - Crashing Patient<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/crashingpatient.com\/medical-surgical\/hypertension-2.htm\/\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" 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