hipertensi emergensi dx and rx (ws)

8/17/2019 Hipertensi Emergensi Dx and Rx (Ws)

1/78

Hypertensive Emergencies:


2/78

Tips for Having your blood

pressure taken.• Don’t drink coffee or smoke cigarettes for

30 minutes before.

• efore test sit for five minutes !it" backsupported and feet flat on t"e ground.

Test your arm on a table even !it" your

"eart.• #ear s"ort sleeves so your arm is

e$posed.


3/78

Tips for "aving blood pressure

taken.• %o to t"e bat"room before test. & full

bladder can affect bp reading.

• %et ' readings and average t"e t!o of

t"em.

• &sk t"e Dr. or nurse to tell you t"e result

in numbers.


4/78

Size Name Cuff Size Bladder Circumference

Small Adult size 22–26 cm 12–24 cm

Adult (regular or standard size) 27–34 cm 16–30 cm

Large Adult size 34–44 cm 16–36 cm

Thigh size 4–2 cm 20–42 cm

Four sized cuffs (minimum adult and large adult cuffs

in room) small adult and t"ig" *uickly available+.

,efer to t"e listed measurements for cuff and bladder.

Note: Manufacturers may have different names for their

various sized cuffs.


5/78

!om"orta#le room tem$erature !old can cause $eri$heral %asoconstriction and decreasing

#lood "lo&' &hich can cause a "alse lo& reading

Table and chair: Ta#le at a height so that the clients

u$$er arm is su$$orted and the #rachial arter* is le%el

&ith heart

!hair arm rests are too lo&

+ ," arm is too lo&- "alse high

+ ," arm is too high- "alse lo&

Procedure Rationale

Wall mount sphygmomanometer:

.osition the monitor at screener e*e le%el and &ithin one

meter "rom the screener

+ Sta*s in cali#ration longer and cant #e dro$$ed

+ /*e le%el in order to mae accurate reading

Cuff size: our cu"" sizes should ideall* #e a%aila#le At

minimum' an adult and large adult cu"" should #e

a%aila#leCuff size with arm and bladder circumferences:

+ Small Adult- 2226 cm' 1224 cm

+ Adult (standard)- 2734 cm' 1630 cm

+ Large adult- 3444 cm' 1636 cm

+ Thigh- 42 cm' 2042 cm

The most common error in #lood $ressure measurement is

the use o" an ina$$ro$riate cu"" size /rrors o%er 30 mmg

can occur i" an undersized cu"" is used+ !u"" #ladder length should #e at least 50 $ercent o" armcircum"erence

+ !u"" #ladder &idth should #e at least 40 $ercent o" armcircum"erence

+ ," cu"" is too small "alse high (more $ressure needed toocclude arter*)

+ ," cu"" too large "alse lo& (less $ressure needed toocclude arter*)

+ ""ice sta"" escorts client to screening area

+ !lient sits 8uietl* "or "i%e minutes #e"ore #lood

$ressure chec &ith legs uncrossed' "eet "lat on the "loor' #ac su$$orted' and u$$er arm #are

+ 9lood $ressure taen &ith legs dangling or unsu$$orted #ac leads to "alsel* high readings (on a%erage "i%e

mmg)+ !rossing the legs ma* increase s*stolic $ressures

As &h* the client is here "or a #lood $ressure chec ,n order to $ro%ide the a$$ro$riate ser%ice "or the client'

as-

+ Are *ou ha%ing s*m$toms:

+ a%e *ou #een instructed #* *our health care $ro%ider toha%e checs:

+ ther 8uestions:

Blood Pressure easurement


6/78

-uff i/e

• ladder width > 40% of

midarm circumference.

• ladder length 80-100%

of arm circumference.

A. Ideal arm circumference

B. ange of acce!ta"le arm

circumferences

#. Bladder length

$. idline of "ladder

&. Bladder width

F. #uff width


7/78

Cause Systolic !ffect

The cu"" is too small (;ost common cause o" error in clinical $ractice


8/78

1scillometric Devices

2easure mean arterial pressure (2&+ and

calculates and D

– The algorithms used are proprietary andNOT standardized

– Results can vary widely and they do not

always closely match BP valuesobtained by auscultation

– These machines must be calibratedregularly

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9/78

2anual vs. &utomatic

• 2anual is t"e gold standard

• 1scillometric measurements preferred

in infants and 4-5 settings 1678

• &ll "ig" readings s"ould be confirmed

!it" a manual


10/78

-onfirming Hig" ’s

• ,epeat in bot" arms and one leg

(bot" not usually necessary+

• ,epeat 3 times to assure accurate

• D$ of HT6 re*uires elevated ’s on 3

separate occasions


11/78

Disappearance of 9HT6 !it"

,epeated 2easurement


12/78

• -ase resentations

• Definitions

• Evaluation

• 2anagement


13/78

-ase ;

• '?0@;A'

>Head -T can s"o!ed ,ig"t basal ganglia"emorr"age !it" s"ift

• H4: Transported by air ambulance to E,. > 4ntubated en route due to declining mental status


14/78

-ase ;

• 2H Hypertension according to !ife=

patient !as nonad"erent !it" prescribed

medications > 1ut patient medications and allergies not

available

> Bamily History Cfor HT6@-&

• E$am E, ;?@;30 > ositive for 7eft dense "emiparesis


15/78

-ase ;

• Hospital day '

> Dilated rig"t pupil

> Emergent rig"t frontotemporal craniotomyand evacuation of clot

• ubse*uent Hospital -ourse

> Difficult to control > neumonia


16/78

-ase ;

• ,enal 2,4

> ,ig"t kidney F.; cm !it" t"ree renal

arteries > 7eft kidney ;'.' cm !it" t!o renal arteries


17/78

Guestion ;

• #"at is t"e primary reason for"ypertensive emergencies today

;. ,enovascular Disease'. "eoc"romocytoma

3. 6onad"erence to anti"ypertensivemedication

I. Hyperaldosteronism


18/78

#"at is t"e primary reason for

"ypertensive emergencies today

;. ,enovascular

Disease

'. "eoc"romocytoma

3. 6onad"erence to

anti"ypertensive

medication

I. Hyperaldosteronism


19/78

Hypertensive Emergency

• &ccording to t"e Joint 6ational

-ommittee on Hypertension ,eport

• everely elevated blood pressure !it"signs and symptoms of acute end organ

damage

• Requires hospitalization

• Requires parenteral medication


20/78

Hypertensive 5rgency

• everely elevated blood pressure

without signs and symptoms of acute

end organ damage• -an be managed as an outpatient

• -an be managed with oral medications


21/78

Hypertensive Emergency

• Damage Heart -HB= 24= angina

Kidneys acute kidneyinLury= microscopic

"ematuria

-6 encep"alopat"y=intracranial "emorr"age=

%rade 3I retinopat"y

asculature aortic dissection=

eclampsia


22/78

Epidemiology

• Hypertensive emergencies are common

> 1ccur in ;'M of t"e "ypertensive population

> ut=


23/78

Epidemiology

• -ommon associations

> revious "istory of "ypertension

> 7ack of a primary care p"ysician

> 6on ad"erence to anti"ypertensive

regimen

> Elicit drug use (cocaine+


24/78

at"op"ysiology

udden increase in

ystemic ascular

,esistance

2ec"anical tress !it"

endot"elial inLury= increased

permeability= -oag@lt

activation= fibrin deposition

;+ Bibrinoid necrosis

'+ 4sc"emia

3+ &ctivation of ,&&

I+ roinflammatory

cytokines


25/78

5nderlying Etiology

• 5nclear= but some candidates

> &-E DD genotype

> &bsence of t"e

β

and γ

subunit of E6a-

> Elevated adrenomedullin levelsN

> Elevated natriuretic peptide levelN

> &bnormalities in o$idative stress markers and

endot"elial dysfunctionN > N-orrect after effective treatment


26/78

Guestion '

• #"at is t"e most common complaint in

"ypertensive emergency

;. 6eurologic defect

'. %ross Hematuria

3. -"est painI. Headac"e


27/78

#"at is t"e most common complaint

in "ypertensive emergency

;. 6eurologic defect

'. %ross Hematuria

3. -"est pain

I. Headac"e


28/78

-linical resentation

• ariable

• Oampaglione et al (Hypertension 'A:;II= ;?+

> ;I= '0 E, visits in one year period

> ;0F met definition of "ypertensive

emergency (0.FM+

> 2ean ystolic ';0 C 3' > 2ean Diastolic ;30 C ;<


29/78

-linical resentation

• Bre*uency of signs and symptoms

> -"est ain 'AM

> Dyspnea ''M

> 6euro defect ';M

> 4nterestinglyP.

• Headac"e !as only 3M and epista$is !as 0Min t"is study


30/78

Guestion 3

• Hypertensive emergency is associated

!it" a t"res"old of

;. ystolic Q ''< mm Hg

'. Diastolic Q ;;0 mm Hg

3. ystolic Q '


31/78

Hypertensive emergency is

associated !it" a t"res"old of

;. ystolic Q ''< mm Hg

'. Diastolic Q ;;0 mm Hg

3. ystolic Q '


32/78

T"res"old

• T"ere is no specific !"ere

"ypertensive emergencies occur

• ut= organ dysfunction is rare !it"diastolic s R ;30 mm Hg

> ,ate of increase may be more important

> Hence= encep"alopat"y !ill occur at lo!ers in pregnancy and in c"ildren


33/78

4nitial Evaluation

• Bocused "istory

> History of "ypertension

> Ho! !ell is "ypertension controlled

> #"at anti"ypertensives

> &d"erence to anti"ypertensive regimen

> 7ast dose of anti"ypertensive


34/78

4nitial Evaluation

• ocial History

> ,ecreational Drugs

• &mp"etamines

• -ocaine

• "encyclidine


35/78

4nitial Evaluation

• -onfirm in bot" arms

• 5se appropriate si/ed cuff

• -uff t"at is too small

> cuffs t"at are too small falsely elevate

measurements in obese patients


36/78


37/78

4nitial Evaluation

• &ssess for endorgan damage

• ascular Disease

> &ssess pulses in all e$tremities

> &uscultate over renal arteries for bruits

• -ardiopulmonary

> 7isten for rales (-HB+

> 2urmurs or gallops


38/78

4nitial Evaluation

• 6eurologic E$am

> Hypertensive Encep"alopat"y mental

status c"anges= nausea= vomiting= sei/ures > 7aterali/ing signs uncommon and suggest

cerebrovascular accident

• ,etinal E$am > 7ost art

> Keit"#agenerarker -lassification


39/78

Keith-Wagener-Barker Classification

• %rade ;

> 2ild narro!ing of t"e arterioles

> 9-opper #ire

• %rade '

> 2oderate narro!ing

-opper !ire and & nicking

• -"anges associated !it" long standing

essential "ypertension


40/78

6ormal


41/78

%rade ;


42/78


43/78

Keith-Wagener-Barker Classification

• %rade 3 > evere 6arro!ing

ilver !ire c"anges= "emorr"age= cotton!ool spots= "ard e$udates

• %rade I > %rade 3 C apilledema

• %rade 3 and I "ig"ly correlated !it"progression to end organ damage anddecreased survival


44/78

%rade 3 K# ,etinopat"y


45/78


46/78

7ab Testing

• E-%

> 7H= look for signs of isc"emia= inLury= infarct

• ,enal Bunction Tests (urine included+ > Elevated 56= -reatinine= proteinuria= "ematuria

• --

• -S, pulmonary edema= aortic arc"= cardiac

enlargement


47/78

7ab Testing

• &ortic Dissection

> uspect !it" severe tearing c"est pain=

une*ual pulses= !idened mediastinum > -ontrast -"est -T can or 2,4

• ulmonary Edema@-HB

> Transt"oracic Ec"ocardiogram > Differentiate bet!een systolic dysfunction=

diastolic dysfunction= mitral regurgitation


48/78

2anagement

• Elevated !it"out target organ

damage

• Hypertensive urgency

• 1ral meds

• %oal gradual reduction of over 'I

IF "ours


49/78

2anagement

• Elevated !it" target organ damage

• Hypertensive emergency

• arenteral meds

• %oal ,educe diastolic by ;0;


50/78

Ho! Guickly

• -erebral lood Blo! &utoregulation > -erebral lood constant in normotensive

individuals over range of 2&s of ?0 ;'0

mm Hg. > 4n c"ronically "ypertensive patients

autoregulatory range is "ig"er

> 2& ,ange ;00;'0 to ;


51/78

Ho! Guickly

• %eneral rule is to lo!er 2& by '0M in

first "our

• "ould al!ays be done !it" closeclinical observation


52/78

2anagement

• #"ere

> 4-5 !it" close monitoring

> evere re*uires intraarterial monitoring

• #"ic" arenteral meds

• Depends on t"e situation


53/78

Guestion I

• #"ic" of t"e follo!ing drugs s"ould notbe used to treat "ypertensive

emergency

;. ublingual 6ifedipine

'. 7abetolol

3. &-E 4n"ibitors

I. 6icardipine


54/78

#"ic" of t"e follo!ing drugs s"ould

not be used to treat "ypertensive

emergency

;. ublingual

6ifedipine'. 7abetolol

3. &-E 4n"ibitors

I. 6icardipine


55/78

referred &gents

• eta blockers

> 7abetolol

> Esmolol

• -alcium Entry blocker

> 6icardipine

• Dopamine; receptor agonist

> Benoldapam

• asodilators nitroprusside@nitroglucerin


56/78

cenarios

• 1ur -ase &cute isc"emic

stroke@cerebrovascular bleed

• &gents > Benoldopam

> 7abetolol

> 6icardipine


57/78

-& or 4sc"emic troke

• elevation after -& or isc"emic stroke can

be protective to preserve cerebral perfusion

• Hold on aggressive lo!ering unless > T"rombolytic t"erapy anticipated or

> e$cessively "ig" ( Q ''0 mm Hg or D

Q;'0+

• %oal for t"rombolytic t"erapy is to lo!er if Q ;F< or D Q;;0


58/78

-ardiac -onditions

• &cute ulmonary Edema !it" systolic

dysfunction

> 6icardipine > Benoldopam

> odium nitroprusside

> 6itroglycerin > 7oop diuretic


59/78

-ardiac -onditions

• &cute ulmonary Edema !it" diastolic

dysfunction

> Esmolol= metoprolol= labetolol > verapamil

> 6itroglycerin

> 7oop diuretic


60/78

-ardiac -onditions

• &cute myocardial isc"emia

> Esmolol= labetolol

> 6itroglycerin


61/78

ympat"etic -risis

• %enerally in association !it"

recreational drugs suc" as cocaine=

amp"etamine or p"encyclidine• udden cessation of clonidine or eta

adrenergic antagonist

• "eoc"romocytoma rare


62/78

Guestion <

• #"ic" of t"e follo!ing drugs s"ould beavoided in sympat"etic crises !it"


;. "entolamine

'. en/odia/epine

3. 7abetolol

I. 6icardipine


63/78

#"ic" of t"e follo!ing drugs s"ould

be avoided in sympat"etic crises !it"


;. "entolamine

'. en/odia/epine

3. 7abetolol

I. 6icardipine


64/78

ympat"etic -risis

• etaadrenergic antagonists !ill resultin unopposed alp"aadrenergic

stimulation• 4n cocaine use= eta blockers can

> 4ncrease blood pressure

> #orsen coronary artery vasoconstriction

> Decrease survival

• Avoid beta blockade (including nonselective agents such as labetolol


65/78

ympat"etic -risis

• ,ecommended Drugs

> 6icardipine

> Benoldopam > erapamil

> en/odia/epine

> 4f p"eo suspected use p"entolamine


66/78

&ortic Dissection

• Treatment is paramount

> A < year survival is A


67/78

&ortic Dissection

• asodilator alone

> -auses refle$ tac"ycardia

> 4ncreases cardiac eLection velocity > 4ncreases aortic s"ear forces

> E$tends t"e dissection


68/78

&ortic Dissection

• tandard t"erapy

> etaadrenergic blocker plus vasodilator

> Esmolol C 6icardipine or fenoldopam

• 6itroprusside can be used as !ell


69/78

&cute ost 1perative Hypertension

• Bre*uent in postoperative state ('0A 4ncreased stress "ormones

> &ctivation of ,&&

• &lso "ypot"ermia= "ypo$ia= carbondio$ide retention= bladder distention


70/78

&cute ost 1perative Hypertension

• revention > afe to give anti"ypertensives preop

> Hold diuretics• Treatment t"res"olds vary

> -ontrol pain and an$iety

>#"ile 61 use nicardipine= esmolol orlabetolol

> ,esume oral medications !"en possible


71/78

#"at "appened to sodium nitroprusside

• 2ansoor and Briedman. Heart -isease

'00') I:3 odium nitroprusside recommended for all

"ypertensive emergencies e$cepteclampsia

• 2arik and aron. !hest '00A) ;3;:;I

> odium nitroprusside recommended for• acute aortic dissection

• acute pulmonary edema !it" systolic

dysfunction


72/78

9riding t"e pride

• Disadvantages of sodium nitroprusside

> Decrease cerebral blood flo! and increases

intracranial pressure

> -an reduce regional blood flo! in coronary artery

disease

> ,isk of cyanide to$icity

• 5se !"en ot"er agents not effective > 2onitor t"iocyanate levels

> &void in renal or "epatic dysfunction


73/78

Have !e made progress

• Birst described by ol"ard and Ba"r > -ie rightsche "ierenkrankenheit+ /linik

0atholgie und Atlas. erlin= %ermany=pringer ;;I:'IA

• Keit"= #agener= arker Am $ Med 1ci2;3);A:33'

> 2ean survival of patients !it" "tn andgrade I retinopat"y !as ;0.< mo !it" noneliving beyond < years


74/78

#e "ave made progress

• Development of anti"ypertensive drugs

• 4ncreased diagnosis of "ypertension

• 4ncreased 4-5 settings

• urvival of patients !it" "ypertensive

urgency and emergency is ;F years

compared to '; years in t"ose !it"uncomplicated "ypertension


75/78

T"ank you

Guestions

#"en you "ear "oof beats


76/78

#"en you "ear "oof beatsP


77/78

2esserli " #ngl $ Med ;


78/78

hipertensi emergensi dx and rx (ws)

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