Download - Approach to Hypertensive Emergency
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Approach toHypertensiveCrises in ED
Dr Mohammad Zikri Ahmad
Emergency Resident HUSM
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Hypertension is classified
into prehypertension, stage Iand stage II hypertension
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Hypertensive crises is a critical elevation in the
BP with markedly elevated diastolic BP (!"#$"mmHg% which incl&des HP' Emergency andrgency
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Hypertensive Emergencies is a spectr&m of clinical presentationwhere &ncontrolled BPs lead to progressive or impending end#organdysf&nction)damage
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Ac&te end#organ damage may incl&de
ne&rological, cardiovasc&lar, renal,retinopathy, or eclampsia
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Hypertensive &rgency* severe elevatedBP associated with imminent E+D
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ook for patients with end
organ damage and re-&ireimmediate I. therapy
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The EP must be capable of treating
the patient and not the number
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It is a prod&ct of failed a&toreg&lation,a/r&pt rise of 0.1 and release ofvasoconstrictors
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2ost commonly presents with C.A,p&lmonary oedema, hypertensiveencephalopathy and CC3
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Cere/ral a&toreg&lation is the a/ility of
the cere/ral vasc&lat&re to maintain aconstant (CB3% across a wide range ofperf&sion press&res4
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1apid rises in /lood press&re can ca&se hyperperf&sion andincreased CB3, which can lead to increased intracranialpress&re and cere/ral edema45 6
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The left ventricle is unable to compensate for an acute
rise in SVR that leads to left ventricular failure and
pulmonary edema or myocardial ischemia.[4 ]
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hen renal autoregulatory system is disrupted! intraglomerular
pressure starts to vary directly "ith the systemic arterial pressure!
thus offering no protection to the #idney during $P fluctuations % this
can lead to acute renal ischemia.[4 ]
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&eath from both ischemic heart
disease and stro#e increaseprogressively as the $P increases
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3+C0History, Physical
E7aminations, Investigationsand 'reatments
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'ake a thoro&gh medication
history to assist intreatments
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Assess whether specific
symptoms s&ggesting E+D(s%are present
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0imilarly, physical e7aminations are toassess whether E+D is there
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2ost patients have a history of inade-&ate hypertensive treatment or an a/r&pt
discontin&ation of their medications
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Don8t forget other ca&ses9
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:o& may want to considerother ca&ses;
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And a foc&sed radiological
st&dies;
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=ell, EC> is a 20'9
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2anaging /egins with correct
differentiation of &rgencyand emergency
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Misconception* a patient never sho&ld/e discharged from the ED with anelevated BP
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Ac&te lowering of BP in the narrowwindow of the ED visit does notimprove long#term mor/idity andmortality rates
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2AP sho&ld /e lowered /y no more than !"? inthe first ho&r of treatment,then /e lowered to @")""#" mm Hg in thene7t !#@ ho&rs if sta/le
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E7ceptions*Hypertensive encephalopathy warrants !?2AP red&ction over ho&rs
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Don8t treat BP in ac&te ischemic stroke&nless !!")!" +1 yo& want to givefi/rinolysis
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'reat Ac&te ICB more
aggressively with target 0BP"mmHg for days
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2aintain 0BPF@"mmHg in 0AH ñfinitive management and addGimodipine
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Aggressively treat dissecting
ane&rysm with target0BPF"mmHg
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In AC0, treat if BP
@")""mmHg /y !"#$"?/aseline red&ction
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.asodilators and
nitroglycerin is the preferredagent for ac&te heart fail&re
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Cocaine to7icity associated HP' and tachycardia doesn8tre-&ire specific treatment /&t alpha#adrenergicantagonists to /e given once AC0 kicks in
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se Hydralaine and
2agnesi&m 0&lfate inpre)eclampsia
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All hypertensive emergency cases need
cons<ation whereas hypertensive&rgencies m&st have an early follow &p
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Admit HP' emergency cases
to intensive care &nit forclose monitoring
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Discharge HP' &rgency
patients with long term careplan
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3ollow Gational Committee
on High Blood Press&rerecommendations
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'ransfer patients to higherlevel of care if necessary
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Always watch o&t for
complications and treat itlike a ticking time /om/
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? of &ntreated HP'emergencies die in year
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3ail&re of 3+C0 will lead tolitigation holoca&st9
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'hank :o&
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Dr&g Apppendi7
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1eferences
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