CaseCase

60 F with PMH HTN, DM, CVA presented to 60 F with PMH HTN, DM, CVA presented to UNC ED CC: seizure. Per the daughter the pt UNC ED CC: seizure. Per the daughter the pt was walking and all of a sudden fell and her was walking and all of a sudden fell and her whole body started shaking. No bladder or whole body started shaking. No bladder or bowel incontinence. Post-ictal in the bowel incontinence. Post-ictal in the ambulance. Vitals HR 84 BP 260/180 RR14 ambulance. Vitals HR 84 BP 260/180 RR14 100% RA100% RA- BP meds Metoprolol 150 mg daily- BP meds Metoprolol 150 mg daily

Amlodipine 10 mg dailyAmlodipine 10 mg daily

What is the diagnosis?What is the diagnosis?

A. Primary Seizure DisorderA. Primary Seizure Disorder B. StrokeB. Stroke C. Hypertensive UrgencyC. Hypertensive Urgency D. Hypertensive EmergencyD. Hypertensive Emergency

Doctor? Doctor? Doctor? Doctor?

A. Head CTA. Head CT B. 12 Lead EKGB. 12 Lead EKG C. CXRC. CXR D. IV Labetalol DripD. IV Labetalol Drip E. Place an arterial lineE. Place an arterial line F. Chemistry, UAF. Chemistry, UA G. Cardiac BiomarkersG. Cardiac Biomarkers

Hypertensive EmergencyHypertensive Emergency

Intern ConferenceIntern Conference

September 2009September 2009

Urgency vs. EmergencyUrgency vs. Emergency

UrgencyUrgencyAny situation in which a rapid decrease in BP is required to Any situation in which a rapid decrease in BP is required to limit end-organ damage.limit end-organ damage.

EmergencyEmergencyElevated blood pressure with evidence of end organ damageElevated blood pressure with evidence of end organ damage

CausesCauses

Malignant HypertensionMalignant Hypertension Aortic dissectionAortic dissection Acute MIAcute MI Acute glomerulonephritisAcute glomerulonephritis Scleroderma renal crisisScleroderma renal crisis PheochromocytomaPheochromocytoma CocaineCocaine EclampsiaEclampsia

End Organ DamageEnd Organ Damage

Unstable anginaUnstable angina Acute myocardial infarctionAcute myocardial infarction EncephalopathyEncephalopathy Acute RetinopathyAcute Retinopathy NephropathyNephropathy LV failureLV failure Dissecting aneurysmDissecting aneurysm

Major Clinical ManifestationsMajor Clinical Manifestations

Retinal hemorrhages and exudatesRetinal hemorrhages and exudates

Major Clinical ManifestationsMajor Clinical Manifestations

PapilledemaPapilledema

Major Clinical ManifestationsMajor Clinical Manifestations

Malignant nephrosclerosis, leading to acute Malignant nephrosclerosis, leading to acute renal failure, hematuria, and proteinuria renal failure, hematuria, and proteinuria

Major Clinical ManifestationsMajor Clinical Manifestations Neurologic symptoms due to intracerebral or subarachnoid bleeding, Neurologic symptoms due to intracerebral or subarachnoid bleeding,

lacunar infarcts, or hypertensive encephalopathy lacunar infarcts, or hypertensive encephalopathy PRES (reversible posterior leukoencephalopathyPRES (reversible posterior leukoencephalopathy

Acutely hypertensiveAcutely hypertensive 1 month later 1 month later normotensivenormotensive

Management of hypertensive Management of hypertensive encephalopathyencephalopathy

The initial aim of treatment in hypertensive The initial aim of treatment in hypertensive emergency is to rapidly lower the diastolic emergency is to rapidly lower the diastolic pressure to about 100 to 105 mmHg; this goal pressure to about 100 to 105 mmHg; this goal should be achieved within two to six hours, should be achieved within two to six hours, with the maximum initial fall in BP not with the maximum initial fall in BP not exceeding 25 percent of the presenting value exceeding 25 percent of the presenting value

DrugsDrugs Nitroprusside — an arteriolar and venous dilator, given as an intravenous Nitroprusside — an arteriolar and venous dilator, given as an intravenous

infusion. Initial dose: 0.25 to 0.5 µg/kg per min; maximum dose: 8 to 10 infusion. Initial dose: 0.25 to 0.5 µg/kg per min; maximum dose: 8 to 10 µg/kg per min. Nitroprusside acts within seconds and has a duration of µg/kg per min. Nitroprusside acts within seconds and has a duration of action of only two to five minutes. action of only two to five minutes.

Concern for what???Concern for what??? Cyanide toxicity with prolonged use and renal failureCyanide toxicity with prolonged use and renal failure

Nicardipine — an arteriolar dilator, given as an intravenous infusion. Nicardipine — an arteriolar dilator, given as an intravenous infusion. Initial dose: 5 mg/h; maximum dose: 15 mg/h. Initial dose: 5 mg/h; maximum dose: 15 mg/h.

Labetalol — an alpha- and beta-adrenergic blocker, given as an Labetalol — an alpha- and beta-adrenergic blocker, given as an intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min. mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min.

Fenoldopam — a peripheral dopamine-1 receptor agonist, given as an Fenoldopam — a peripheral dopamine-1 receptor agonist, given as an intravenous infusion. Initial dose: 0.1 µg/kg per min; the dose is titrated at intravenous infusion. Initial dose: 0.1 µg/kg per min; the dose is titrated at 15 min intervals, depending upon the blood pressure response15 min intervals, depending upon the blood pressure response

Oral TherapyOral Therapy

Once BP is controlled transition the patient to Once BP is controlled transition the patient to oral therapyoral therapy Start orals while drip is still going and allow nurse Start orals while drip is still going and allow nurse

to wean the drip based on the MAPto wean the drip based on the MAP Be careful not to overshoot and cause hypotensionBe careful not to overshoot and cause hypotension

PrognosisPrognosis

Even with adequate antihypertensive therapy Even with adequate antihypertensive therapy most patients still have moderate to severe most patients still have moderate to severe vascular damage occurringvascular damage occurring At higher risk for coronary, cerebrovascular and At higher risk for coronary, cerebrovascular and

renal diseaserenal disease

CaseCase

Head CT to evaluate for edemaHead CT to evaluate for edema MRI to evaluate for strokeMRI to evaluate for stroke Every hypertensive emergency deserves an Every hypertensive emergency deserves an

examination of renal artery stenosis via examination of renal artery stenosis via dopplers or MRAdopplers or MRA

Take Home PointsTake Home Points

In hypertensive emergency, control the In hypertensive emergency, control the diastolic blood pressure within the first two to diastolic blood pressure within the first two to six hours with IV drip and with an arterial line six hours with IV drip and with an arterial line in stepdown or ICUin stepdown or ICU

Perform a fundoscopic exam upon admissionPerform a fundoscopic exam upon admission Transition to oral therapy once goal is Transition to oral therapy once goal is

achieved achieved Diastolic BP should be reduced to 85-90 over Diastolic BP should be reduced to 85-90 over

two to three months.two to three months.