Ht n Emergency
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Transcript of Ht n Emergency
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HYPERTENSION
Emergencies & Urgencies
Stephen S. Levin, D.O.
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Definitions
EmergenciesSymptomaticAcute End-Organ Damage
Diastolic B.P. usually >130 mmHg
Urgencies
AsymptomaticNO Acute End-Organ DamageDiastolic B.P. usually >110 mmHg;
Systolic B.P. usually >180 mmHg
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Begin Treatment!This is a Hypertensive Emergency
Begin to look for other causes of symptoms
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Principles of Therapy
Lower B.P. over hours
Initial goal B.P. 160s/90s
Too rapid lowering may cause direconsequences (CVA, MI)
May take several days to get to
reasonable levelsAvoid medications that cannot be
controlled (sublingual nifedipine)
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Hypertensive Emergencies: Treatment
For most patients the greatest risk of
treating a hypertensive emergency isthe risk of accompanying hypotension.
Treat with short acting, easilytitratable, I.V. drug.
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Parenteral Drugs for Treatmentof Hypertensive Emergencies
Drug Dosage Onset Duration Adverse
Effects
Indic.(I)
Contrain.(C)
VasodilatorsNitroprus-side
0.3-10mcg/kg/minIV infusion
1-2 min. 1-2 min. N/V,mus.twitch.,cyanide,thiocyan.tox.
intracran.pressure
I: CHF,aorticdissect.,
catechol.
C: hepatic,renal
insuff.Nitrogly-cerin (IV)
5-100mcg/kg/min
2-5 min. 3-5 min. HA,dizziness,vomit.,methemglo.tolerance
I: coronarydis., CHFC: CVAintracran.
pressure
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Parenteral Drugs for Treatmentof Hypertensive Emergencies
Diazoxide(HyperstatIV)
1-3 mg/kg(up to 150mg) IVbolus, q5-
15 min;repeat q4-24 hr asneeded
2-4 min 3-12 hr Nausea,hypotension,flushing,tachycardia,
hypergly-cemia,aggravationof angina,fluidretention
C:Syndromes ofcoronaryinsufficiency,
(unless usedwith beta-blockingagent),cerebrovascular accident,hypersensi-
tivity tosulfonamides
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Parenteral Drugs for Treatmentof Hypertensive Emergencies
Fenoldopammesylate(Corlopam)
0.1-1.7micrograms/kg/minIV infusion
5-15min 1-4 hr Headache,dizziness,flushing,increasedintraocularpressure,hypokalemia,dose-relatedtachycardia
I: Severehyperten-sion withrenal insuffi-ciencyC: Glaucoma
HydralazineHCl(Apresoline)
10-20 mg IV or IMbolus, repeat q4-6 hras needed (maximumdose, 40 mg)
10-20min
3-8 hr Tachycardia,flushing,headache,vomiting,
aggravationof angina
I: CHFC: Coronaryinsufficiency,aortic
dissection,cerebrovas-cular accident(may increaseintracranialpressure)
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Parenteral Drugs for Treatmentof Hypertensive Emergencies
Enalaprilat(Vasotec I.V.)
1.25-5 mg q6hr IV
15min
6 hr Precipitous drop inblood pressure inhigh-renin states,
variable response
I: CHFC: Use withcaution in
patients withsevere renalinsufficiency(not receivingdialysis)
NicardipineHCl(Cardene)
5-15 mg/hr
IV infusion
5-20
min
1-2
hr
Tachycardia,
headache, flushing,local phlebitis
C: Greater
than first-degree heartblock, CHF
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Parenteral Drugs for Treatmentof Hypertensive Emergencies
Adrenergic InhibitorsPhentol-amine(Regitine)
-blocker
5-20 mg IV,repeat asnecessary
1-2min
10-30min
Tachycardia,nausea,flushing,
abdominalpain,aggravationof angina
I:Catecholamineexcess
C: Syndromesof coronaryinsufficiency
EsmololHCl
(Brevibloc)
200-500micrograms/kg/
min over 1-4min, then 50-300micrograms/kg/min IV infusion
1-2min
10-20min
Hypotension,nausea,
bradycardiaor heartblock,dizziness
I: Syndromes ofcoronary
insufficiencyC: Greater thanfirst-degreeheart block,CHF
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Parenteral Drugs for Treatmentof Hypertensive Emergencies
LabetalolHCl(Normo-dyne,
Trandate)-
blocker
20-80 mgIV bolus,repeat asneeded
(maximum dose,300 mg);or 2mg/minIV
infusion
2-10 min 2-4 hr Hypoten-sion,nausea,itching,
scalptingling,dizziness
I:Synd-romes ofcoronaryinsuffi-
ciency,catechol-amineexcessC:> first-degree
heartblock,CHF,bronchialasthma
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Fenoldopam: Indications
In-hospital, short-term (up to 48 hours)management of severe hypertensionwhen rapid, but quickly reversible,emergency reduction of blood pressure
is clinically indicated, includingmalignant hypertension withdeteriorating end organ function.
Transition to oral therapy with anotheragent can begin at any time after bloodpressure is stable during fenoldopaminfusion.
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Fenoldopam:
Adverse EventsHeadache
FlushingNausea
Hypotension
Hypokalemia
EKG Abnormalities
Tachycardia
Vomiting
Dizziness
ExtrasystolesDyspnea
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Nicardipine: Characteristics
Dihydropyridine
Reflex tachycardia
Useful when-Blockerscontraindicated
Water soluble andlight stable(allows for IV infusion)
Slow onset andoffset
Arterial catheter notmandatory
May accumulate
Variable duration of
hypertensive effectGood in patients
with renal disease
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Therapy Hypertensive Urgencies
Oral meds. Preferred
Close monitoring
Fast follow-up
Start with short acting forms(not Ca+2channel blockers)
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Drugs for Urgencies
Clonidine
-Blockers, -Blockers
Captopril, Enalapril
Minoxidil (if already on -blocker& diuretic)
Hydralazine
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Drug Related
Malignant Hypertension
MAO Inhibitors
Cold Preparations
Withdrawal Antihypertensive Meds
Clonidine,
-BlockersStreet Drugs
Cocaine, PCP