Approach to Hypertensive Emergency

8/13/2019 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 &ntildefinitive 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&ltation 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


Approach to Hypertensive Emergency

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