1、Management of Hypertension and Hypotension in the Emergency Department,Hypertension,How do we manage Hypertension in the ER?,Hypertension Management in the ED,Annual Census = 78,000 patients Approximately 215 patients per day 40 to 50% have elevated BP readings upon admission to the ED That is rough
2、ly 39,000 patients/yr with elevated blood pressure readings in the ER.,First Step: Categorize Types of Hypertension,Four Categories of Hypertension,- Hypertensive Emergency- Hypertensive Urgency- Acute Hypertensive Episode- Transient Hypertension,What is a Hypertensive Emergency?,Hypertensive Emerge
3、ncy,- A relative increase in blood pressure from baseline combined with Target Organ Dysfunction (TOD) No Defined Pressure Measurement Target Organ Damage is evident Also known as Hypertensive Crisis or Malignant Hypertension The MOST Serious form of hypertension,How do we define Target Organ Dysfun
4、ction ?,Target Organ Dysfunction,Evidence of Damage or Injury to “Target Organs” such as the Heart, Brain, Lungs, Kidneys, or Aorta.,Examples of Target Organ Dysfunction,Acute MI/ Unstable Angina CVA ICH / Subarachnoid Hemorrhage CHF Aortic Dissection Acute Renal Failure Hypertensive Encephalopathy,
5、How do we determine if Target Organ Dysfunctionis present?,Evaluation for Target Organ Dysfunction,1. EKG: (Evaluation for ST elevation or depression, new T-wave inversions, LVH, or new Left BBB)CXR: (CHF/pulmonary edema, cardiomegaly, widened mediastinum)UA or urine dip: (looking for proteinuria, r
6、ed cells, or red cell casts)Chem 8: (elevated BUN/CR indicating acute renal insufficiency or failure, look for other etiologies causing mental status changes, like hypoglycemia)Neurological Exam: (Evaluate for lateralizing signs and symptoms)Funduscopic Exam: (looking for papilledema or hemorrhages)
7、7. CT Head: (only if neurological findings are suspicious for acute CVA),Diagnosis and Management ofHypertensive Emergency,Hypertensive Encephalopathy,Pathophysiology: - Loss of Cerebral Autoregulation of blood flow resulting in hyperperfusion of the brain, loss of integrity of the blood brain barri
8、er, and vascular necrosis. Loss of Autoregulation occurs at a constant cerebral blood flow of above MAP 150 to 160 mmHg. Acute Onset Reversible,Hypertensive Encephalopathy,Symptoms: Headache, Nausea/Vomiting, Lethargy,Confusion, Lateralizing neurological symptomsthat are not often in an anatomical d
9、istribution. Signs: Papilledema, Retinal HemorrhagesDecreased level of consciousness, ComaFocal neurological findings,Management of Hypertensive Encephalopathy,Reduce Mean Arterial Pressure (MAP) by 20 to 25% (T.397) and do not exceed this within first 30 to 60 min. Rosen recommends reduction of 30
10、to 40% (R.1759) MAP= 1/3(SBP-DBP) + DBP Treatment Reduces vasospasm that occurs at these high pressures Avoid excessive BP reduction to prevent hypoperfusion of the brain and further cerebral ischemia,Management of Hypertensive Encephalopathy,- Nitroprusside is the agent of choice (T.397) and (R.175
11、9)- Nitroglycerin and Labetalol have been used successfully, but have not replaced Nitroprusside,Management of Ischemic CVA,Ischemic CVA,Pathophysiology: Elevated Blood Pressure can be the cause of the central nervous system event, OR, it may be a normal physiologic response (Cushings Reflex),Ischem
12、ic CVA Management,Elevated blood pressure is usually a physiologic response to the stroke itself and NOT the immediate cause This elevation of blood pressure maintains cerebral perfusion to viable but edematous tissue surrounding the ischemic area. Most embolic or thrombotic strokes do NOT have subs
13、tantial BP elevations and do not need aggressive therapy,Ischemic CVA Management,Management: VERY CONTROVERSIAL!Recent Trends leans towards NOT treating hypertension in the presence of a Cerebrovascular Accident (thrombotic or embolic) unless Diastolic Blood Pressure exceeds 140mmHg.,Ischemic CVA Ma
14、nagement,Tintinelli: Favors lowering MAP (mean arterial pressure) by 20%. Recommends IV Labetalol in small doses of 5mg increments IF Diastolic Blood Pressure is higher than 140 mmHg.(T. 398),Ischemic CVA Managment,Rosen: In most cases, recommends no treatment of Hypertension in CVA patients. (p. 17
15、60). - However, the author does recommend treating HTN if diastolic blood pressure is greater than 140 mmHg.,Management of Hemorrhagic CVA,Causes of Hemorrhagic CVA,Hypertensive Vascular Disease Arteriovenous Anomalies (AVM) Arterial Aneurysms Tumors Trauma,Hemorrhagic CVA Management,Hypertension as
16、sociated with hemorrhagic stroke is usually transitory and the result of increased intracranial pressure and irritation of the Autonomic Nervous System,Hemorrhagic CVA Management,Hemorrhagic CVAs commonly results in a profound reactive rise in blood pressure Management is CONTROVERSIAL. Subarachnoid
17、 Hemorrhage: oral nimodipine (nimotop) 60mg po q 4 hours to reverse vasospasm. (T.398) Nicardipine: 2mg IV boluses followed by an IV infusion of 4 to 15 mg/hr is used by some to treat Subarachnoid Hemorrhage. (T.398),Management of CHF/Pulmonary Edema,Congestive Heart Failure / Pulmonary Edema,Pathop
18、hysiology: Increased Afterload with decreased Cardiac Output,CHF / Pulmonary Edema,Symptoms:Shortness of Breath, Cough, Chest PainLower Extremity SwellingSigns:Jugular Venous Distension, Rales, S3 GallopHepatomegaly, Pedal Edema,CHF / Pulmonary Edema Management in the ED,Nitroprusside or IV Nitrogly
19、cerin (T. 398) Rosen: May start with Nitroglycerin, but Nitroprusside is agent of choice if Pulmonary Edema is present. (R. 1760) Attempt treatment of CHF initially with standard agents (Lasix,sublingual NTG, morphine), as these often lower blood pressure, but resort to Nitroprusside if necessary (R
20、. 1761),Management of AcuteCoronary Syndrome/Acute MI,Acute Coronary Syndrome / Acute MI,Pathophysiology:- Increased afterload, cardiac workload, and myocardial oxygen demand- Decreased coronary artery blood flow,Acute Coronary Syndrome / Acute MI,Symptoms:Chest Pain, Nausea / Vomiting, Diaphoresis,
21、Shortness of BreathSigns: Congestive Heart Failure Signs, S4 Gallop(due to decreased ventricular compliance)Few physical findings in many patientsClinical History is very Important,Acute Coronary Syndrome/ Acute MI,Immediate Blood Pressure reduction is indicated to prevent Myocardial Damage No speci
22、fic Defined BP target Tailor treatment to symptom relief(T. 398),Acute Coronary Syndrome / Acute MI,Management: Nitroglycerin IV or Sublingual (T. 398)Nitroprusside (T. 398)Beta Blockers (Esmolol,Lopressor) (T. 356-357)Nitroglycerin is Drug of Choice (R. 1761),Dissection of Thoracic Aorta,Dissection
23、 of Thoracic Aorta,Pathophysiology: - Atherosclerotic Vascular Disease, Chronic Hypertension, increased shearing force on the thoracic aorta, leading to intimal tear. - 50% begin in ascending aorta - 30% at aortic arch - 20% in descending aorta (R.1762-3),Dissection of Thoracic Aorta,Symptoms: Chest
24、 pain radiating to the back (classic presentation) Neurological Symptoms (carotid artery dissection) Angina (coronary artery dissection) Shortness of breath (aortic insufficiency, cardiac tamponade)Signs: - Differential Blood Pressure (in UE) Bruit (interscapular) Neurological Deficits Acute Cardiac
25、 Tamponade (rare),Dissection of Thoracic Aorta,Management: Medications with negative inotropic effects (beta-blockers) MUST be given FIRST. (reduces shearing force)Vasodilators (nitroprusside) may be added for further antihypertensive treatment after administration of a negative inotropic agent.,Dis
26、section of Thoracic Aorta,Optimal Blood Pressure in these patients is undefined and must be tailored for each patient, however, SBP of 120-130mmHg may be a intial starting point. (T.408),Acute Renal Failure,Acute Renal Failure,Pathophysiology:Hypertensive Glomerulonephropathy, Acute Tubular Necrosis
27、 (ATN)- Worsening renal function in the setting of severe hypertension with elevation of BUN/CR, proteinuria, or the presence of red cells and red cell casts in the urine.,Acute Renal Failure,Symptoms: - Many times there are few actual symptoms Facial or Peripheral Edema due to fluid overload or pro
28、teinuria may be present, shortness of breathSigns: Few findings unless edematous Pulmonary Edema,Acute Renal Failure,Management:Nitroprusside is agent of choice (T.398) Dialysis (as needed) Rosen: Lasix to enhance Sodium excretion; Also recommends Nitroprusside or Nifedipine (R.1761) Nitroglycerin i
29、s also a good agent in this setting since it is hepatically metabolized and gastrointestinally excreted.,Pheochromocytoma,Pheochromocytoma,Pathophysiology:- Alpha and Beta stimulation of the cardiovascular system due to adrenergic excess states,Pheochromocytoma,Symptoms: Episodic Headaches, flushing
30、, tremor, diaphoresis, diarrhea, hyperactivity, and palpitationsSigns:Tachycardia, tachypnea, tremor, hyperdynamic state (high output CHF),Pheochromocytoma,Management: Alpha Blocker FIRST, followed by a Beta Blocker Phentolamine (alpha) + Esmolol (beta) Labetalol IV (combined alpha and beta blockade
31、),Toxemia of PregnancyEclampsia/Pre-Eclampsia,Toxemia of Pregnancy,Pathophysiology:Systemic arterial vasoconstriction (including placental, leading to decreased uterine blood flow). Defined as SBP = 140/90 mmHg or greater, OR a 20 mmHg rise in SBP or 10 mmHg rise in DBP from baseline and evidence of
32、 HELLP Syndrome,Toxemia of Pregnancy,Symptoms:Lower extremity swelling, headache, confusion, seizures, comaSigns:Edema, hyperreflexia, elevation of blood pressure related to baseline BP prior to pregnancy (elevation may be mild 125/75),Toxemia of Pregnancy,Management: IV Magnesium Sulfate, Hydralazi
33、ne. May also use nifedipine or labetalol (R.1762) Delivery of Fetus is definitive treatment of pre-eclampsia,Summary of Medications used for Hypertensive Emergencies,- Intravenous Nitroglycerin:Start at 0.2 to 0.4 mcg/kg/min (10 to 30 mcg/min) and rapidly increase in 5 to10 mcg/min increments. Titra
34、te to BP and symptomatic improvement. (T.369)- Nitroprusside: Start 0.3 mcg/kg/min and titrate up every 5 to 10 minutes based on BP and clinical response. (T.369)- Esmolol: 500 mcg/kg initial bolus over 1 minute, then start infusion at 50 to 150 mcg/kg/min (T.408)- Metoprolol (Lopressor): 5mg IV eve
35、ry 2 minutes for a total of 3 doses, then start infusion at 2 to 5 mg/hr. (T.408),Summary of Medications used for Hypertensive Emergencies,- Labetalol: 20mg IV initial dose, with repeat doses of 40mg to 80mg every 10 minutes to reach desired effect or max dose 300mg. (T. 408)Nicardipine: 2mg IV bolu
36、ses followed by an IV infusion of 4 to 15 mg/hrMagnesium Sulfate IV: 4 to 6 grams over 15 minutes, followed by IV infusion of 1 to 2 grams/hour Hydralazine: 10 to 20mg IV,What is a Hypertensive Urgency?,Hypertensive Urgency,- A relative increase in blood pressure from baseline WITHOUT current eviden
37、ce of TOD, but potential of progression to TOD is HIGH.- Increased likelihood when pre-existing conditions are present(renal insufficiency, CAD, CHF),Hypertensive Urgency,Current recommendation is the gradual reduction of blood pressure within 24 to 48 hours by using oral antihypertensive agents Non
38、-compliance is a common cause, therefore, restarting a current regimen of blood pressure medication is appropriate Making needed changes to current blood pressure medication regimens is also appropriate Follow-up within 24 hours should be arranged with Primary Care Physician,Oral Regimens for Treatm
39、ent of Hypertensive Urgency in the ED,(Tintinelli pg. 402)Clonidine: 0.1 to 0.2mg PO, repeat 0.1mg q hour to desired BP reduction or max of 0.7mg. Labetalol: 200 to 400mg PO, repeat every 2 to 3 hours Captopril: 25mg PO Losartan: 50mg PO,What is an Acute Hypertensive Episode?,Acute Hypertensive Epis
40、ode,Elevation of Blood Pressure relative to baseline, but WITHOUT evidence of acute OR impending Target Organ Dysfunction (TOD),Management of Acute Hypertensive Episode,Paucity of evidence that acute intervention in ED is warranted for Hypertensive Episode Complications can occur in acute treatment
41、of patients with chronically elevated blood pressure If HTN is newly diagnosed in the ER, patients should be referred to Primary Care physician for evaluation and initiation of therapy within 24 to 48 hours Again, restarting prior blood pressure medication regimens or adjusting doses is appropriate
42、for patients with previously diagnosed hypertension.,What is Transient Hypertension?,Treatment of Transient Hypertension,Transient HTN occurs in association with other conditions like anxiety, alcohol withdrawal syndromes, toxicological substances, and sudden cessation of medications) Treatment is a
43、imed at underlying cause “White-Coat Hypertension” Single encounter in ED does not warrant diagnosis of HTN or treatment of HTN Follow-up with Primary Care Physician,SWITCHING GEARS,Hypotension/ShockManagement in the ED,Hypotension/Shock,Types of Shock:- Hypovolemic (inadequate circulating volume)-
44、Cardiogenic (inadequate pump function)- Distributive (peripheral vasodilitation)- Obstructive(extra-cardiac obstruction of blood flow),Hypotension/Shock Goals of Management,1. Determine Cause:- Usually very apparent- Can be subtle- No single Vital Sign that is diagnostic of Shock- Initial Therapy gu
45、ided by clinical findings,Management of Hypotension/Shock,2. Evaluate Signs and Symptoms:- Tachycardia- Decreased Urine Output- Cool, Mottled Skin- Cyanosis- Confusion,Hypotension/Shock Goals of Resuscitation,ABCs: A- Secure Airway (intubate if needed)B- Insure oxygenation and ventillationC- Provide
46、 Hemodynamic Stabilization (correction of hypotension based on etiology),Resuscitation,Initiate Fluid Therapy: 0.25 to 0.5 Liters of Normal Saline (NS) or similar isotonic crystalloid should be administered every 5 to 10 minutes as needed for correction of hypotension,Rapid Fluid Administration,It i
47、s not unusual for a patient to require 4 to 6 Liters of fluid in the initial phase of resuscitation.,Goal of Fluid Resusciation,Stabilization of pts mentation Improvement in Blood Pressure Reduction of Pulse Rate Improved Skin Perfusion Urine Output 30ml per hour,Inotropic Support,If NO response to
48、initial fluid infusion of 3 to 4 L is noted, OR if there are signs of fluid overload (pulmonary edema), Inotropic agents should be started.,Inotropic Agents,Dopamine: Start infusion at 5 mcg/kg/min and titrate up to 20 mcg/kg/min in order to achieve desired BP Indicated for reversing hypotension rel
49、ated to AMI, trauma, sepsis, heart failure, and renal failure when fluid resuscitation is unsuccessful or not appropriate (T. 212),Inotropic Agents,Dobutamine: Dosage range is 2 to 20 mcg/kg/min, however, most patients can be maintained at a rate of 10 mcg/kg/min Indicated for cardiovascular decompe
50、nsation due to ventricular dysfunction or low-output heart failure Agent of choice for management of Cardiogenic Shock Less effect on Heart Rate than Dopamine(T. 212),Inotropic Agents,Norepinephrine (Levophed): start infusion at 2 mcg/min and titrate to achieve desired blood pressure. Used when there is inadequate response to other pressors. Lowest dosage that maintains BP should be used in order to minimize the complications of vasoconstriction Increased survival rates of up to 40% in septic shock have been reported in the literature(T. 246),
