Download Hypertensive Urgency

Hypertensive
Urgency/Emergency
Tanya Null
Hypertensive Crisis
• Broken down in to two groups:
1.Hypertensive Urgency
2.Hypertensive Emergency
Hypertensive Urgency
Is a situation when the blood pressure is acutely elevated.
Defined per the American Heart Association as a Systolic BP of 180 or
greater or a Diastolic BP of 110 or greater.
With a hypertensive urgency, there are no symptoms of acute-end organ
dysfunction
Hypertensive Emergency
 Is an emergent situation when the blood pressure is elevated
Defined by the American Heart Association as a Systolic BP of 180 or
greater and or a diastolic BP of 120 or greater
With a hypertensive emergency, the patient will have signs of acute,
ongoing organ damage.
Pathogenesis
Noncompliance with medications
Illicit drug use
Renal disorders
Pheochromocytoma
Spinal cord injury causing increased intracranial pressure
Clinical Manifestations of hypertensive
urgency
 Headache
Shortness of Breath
Nosebleeds
Anxiety
Clinical Manifestations of hypertensive
emergency
Any signs and symptoms of acute organ damage such as
1. Chest pain
2. Asymmetry between pulses and or back pain
3. Shortness of breath, crackles, and or jugular venous distention
4. Numbness or weakness
5. Confusion, coma
6. Headache
7. Vision impairment
8. Hematuria
Subjective/Social Assessment
• Has the patient ever been diagnosed with hypertension?
• If so is the patient compliant with medications? And what are the
medications?
• If the patient has no history of hypertension, is there a family
history of hypertension?
Does the patient smoke, drink alcohol, or do any illicit drugs?
• Is the patient under a lot of stress?
• What is the patients surgical and past medical history?
Objective Assessment
• Any patient with an elevated blood pressure consistent with
hypertensive crisis needs to have a full through head to toe
assessment with special focus on:
Neurological
Cardiovascular
Pulmonary
Renal
Cotton wool spots
Appear as fluffy white
patches on the retina
Caused by damage to
nerve fibers
Papilledema
 Is optic disc
swelling
Differential Diagnosis
• Is this an acute or chronic problem
• Do Not MISS or RED FLAGS
•
1. Pheochromocytoma
•
2. Ischemic Stoke or Intracerebral Hemorrhage
•
3. Aortic Dissection
•
4. Acute MI
Diagnostic testing
Blood Pressure
Electrocardiogram
Chest xray
 CT of the head
Urinalysis
Basic Metabolic Panel
Funduscopic evaluation
Treatment of Hypertensive emergency
• If organ dysfunction or damage is confirmed the patient will need to be
admitted to an intensive care unit for close monitoring and intravenous
medications.
• Nicardipine
• Esmolol
• Nitroglycerin
• Clevidipine,
• Labetalol
• Nitroprusside
• Loop diuretic
• Benzodiazepines
Goal of Therapy for Hypertensive Emergency
• 25% drop in the mean arterial pressure in minutes to 1 to 2 hours.
• Exception is those patients suffering from an aortic dissection or
ischemic stroke.
• Over a time period of 2 to 6 hours blood pressure goal should be
around 160mmHG/100mmHG
• After 48 hours and once the blood pressure is controlled oral
agents can be started and the patient should be weaned off of the
intravenous medications.
Treatment for Hypertensive Urgency
• If the patient has a history of chronic hypertension and is non
compliant with medications, it is recommended that the patient
be started back on their previously prescribed regimen.
• If the patient with chronic hypertension is compliant with
medications, it is recommended that the dose of current
medications be increased if possible or a new agent be started.
• If this is a new diagnosis of hypertension for the patient clonidine,
captopril, and or nifedipine are good choices for treatment.
Goal of Treatment for Hypertensive Urgency
• Blood pressure should be lowered gradually over a period of days
• This is something that can usually be done on an outpatient basis.
• It is very important that these patients understand the importance
of a 24-48 hour follow up.
• They also need to be educated on medication compliance.
References
• In Papadakis, M. A., In McPhee, S. J., & In Rabow, M. W. (2016). Current medical
diagnosis & treatment 2016. McGraw Hill Education.
• Hypertensive Crisis. (2015, October 22). Retrieved from
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPr
essure/Hypertensive-Crisis_UCM_301782_Article.jsp#.Vsi3peaYLIU
• Management of severe asymptomatic hypertension (hypertensive urgencies) in
adults. (2014, May 6). Retrieved from
http://www.uptodate.com/contents/management-of-severe-asymptomatichypertension-hypertensive-urgencies-in-adults
• Evaluation and treatment of hypertensive emergencies in adults. (2014, July 7).
Retrieved from http://www.uptodate.com/contents/evaluation-and-treatment-ofhypertensive-emergencies-in-adults
• Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and
management of the adult patient. Philadelphia, PA: Lippincott Williams & Wilkins.