Allopathy Medical Awareness for doctors
Modern Management of Hypertensive Emergencies
Hypertensive Emergency - When there is evidence of end organ damage along with raised blood pressure with symptoms:
+ Thunderclap Headache
+ Ripping chest pain front to back
+ Difficulty in breathing
+ Pink Frothy Sputum
+ Sudden vision loss
BP is really high, and its killing the organs (180 / 120, target organ dysfunction)
I. Types:-
1. Neurological
* Subarachnoid hemorrhage (SAH)
* Stroke - ichemic, PRESS, Hemorrhage
* Hypertensive Encephalopathy
> Altered mental status because of Htn only
2. Vascular
* Aortic Dissection
3. Cardiac
* Acute coronary syndrome (ACS)
4. Respiratory
* Pulmonary Edema - Flash Pulmonary Edema
5. Renal
* Acute Renal Failure
6. Other
* Retinal hemorrhage
* Preeclampsia
* Pheochromocytoma
II. Investigations:-
* CBC & basic chemistry panel to assess for acute renal insufficiency.
* An ECG & cardiac troponin to evaluate for myocardial injury.
* Urine may reveal protein-uria or hemat-uria in patients with renal injury.
* CXR or bedside ultrasound are useful for demonstrating pulmonary edema due to left ventricular failure.
* In patients with neurologic complaints, CT imaging of the brain may demonstrate hemorrhage or ischemia, although magnetic resonance imaging (MRI) is often needed for radiographic verification of posterior reversible encephalopathy syndrome.
Goal is to Lower the BP but not too fast:-
* 20-25% in first hour
* Which Pressure to lower
* Systolic Pressure (reduces bleeding risk)
* Preferably put arterial line, even central line if needed
* First choice is Nicardipine
* Initial dose 2.5-5 mg/h IV titrate to effect (max 15 mg/h)
* In small hospitals/clinics there may be Nifedipine capsule. Ten mg capsule can be broken & put sublingual to reduce the BP.
* Then, we can choose as per patient profile & associated cause.
III. Choices of Medication:-
1. Aortic Dissection
* Reduce Heart rate & BP; both.
* Start with Esmolol
* Add Nicardipine
* Labetalol - 10-40 mg IV bolus, then 2-8 mg/min
* 7 times more beta blockade than alpha, not much titratable
* Target is 120 - 60
2. ACS
* NTG - quick, titratable
* Pulmonary Edema - Bipap also
3. Renal
* Renaldopam - less renal injury
* Nicardipine
4. Preeclampsia
* Magnesium
IV. Categories of Neuro Problems with Hypertension:-
1. Subarachnoid Hemorrhage
* 210 / 110
* Goal is < 140, quickly
* Risk of re-rupture - increase mortality
* Nicardipine
* Labetalol
* Nitroprusside / NTG to be avoided
2. Traumatic Brain Injury
Case 1 -
* 10 yr old guy, history of fall, on warfarin, SDH
* 210 / 110
* Goal is to keep CPP up, 50-60 (MAP-ICP)
* Artery is trying to stay open, bleed has caused damage, but if you add ischemia, that will add stroke
* May be Fentanyl for pain
* Don't decrease too far too fast
* Keep SBP > 100 - 110 irrespective of age
* If it is less, increase the BP
Case 2 -
* History of trauma, normal CT, GCS 6
* 210 / 110
* Diffuse Axonal injury
* Treat pain, bring BP to less than 180 but not too down
* Use Analgesia to decrease BP, 20-30%
* Little Labetolol can be used
* Post intubation sedation analgesia
3. Intracerebral Hemorrhage
Case 3 -
* 60 yr woman, on antiplatelets, 190/110
* Basal Ganglia bleed
* Severe headache
* Quickly bring down the BP
* Goals are to keep it less than 180-140
* It depends on where he/she lives (220 or 170)
* Nicardipine infusion, Labetolol
* If bleed is small, then too you need to decrease the BP
4. Acute Ischemic Stroke
Case 4 -
* 65 yr male presenting with Hemiplegia
* 210 / 110
* Higher BP have better outcomes
* Perfusion of the penumbra via collateral circulation
* Decrease from 210, but don't bring down too much.
Summary:-
* Subarachnoid Hemorrhage - < 140, quickly, nicardipine, labetolol
* Traumatic > 100 - 110
* TBI without hemorrhage - as high to keep perfusion, use fentanyl first
* Intracerebral hemorrhage - quickly, nicardipine, labetalol, < 180, < 140
* Acute ischemic stroke - < 180 but on higher side
Case 5 -
Patient comes to ICU with BP of 190/110.
Patient fears about Heart attack, stroke, etc.,
Hold on, is it emergency?
It is hypertension, but not emergency because patient looks well & feels well. Do counselling. Manage slowly over days on OPD basis.