PowerPoint Presentation

CRISIS HIPERTENSIVASDr. Luis Leonardo Chacn PradoResidente de medicina Interna - UCRPicture triptych(Intermediate)

Tip: For best results with the effects on this slide, use pictures with a portrait (vertical) orientation.

To reproduce the picture effects on this slide, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank.On the Insert tab, in the Illustrations group, click Picture. In the Insert Picture dialog box, select a picture, and then click Insert. Select the picture. Under Picture Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Size tab, resize or crop the picture as needed so that under Size and rotate, the Height box is set to 3.5 and the Width box is set to 2.35. Resize the picture under Size and rotate by entering values into the Height and Width boxes. Crop the picture under Crop from by entering values into the Left, Right, Top, and Bottom boxes. On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align to Slide.Click Align Center.On the Home tab, in the bottom right corner of the Drawing group, click the Format Picture dialog box launcher. In the Format Picture dialog box, click Line Color in the left pane. In the Line Color pane, select Solid line, click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 25% (fourth row, second option from the left). Also in the Format Picture dialog box, click Line Style in the left pane, and then in the Line Style pane, in the Width box, enter 8 pt.Also in the Format Picture dialog box, click Shadow in the left pane. In the Shadow pane, click the button next to Presets, and then under Perspective, click Perspective Diagonal Upper Right (first row, second option from the left).Also in the Format Picture dialog box, click 3-D Format in the left pane, and then do the following in the 3-D Format pane:Under Bevel, click the button next to Top, and then under Bevel click Relaxed Inset (first row, second option from the left). Next to Top, in the Width box, enter 8 pt, and in the Height box, enter 6 pt. Under Depth, click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 25% (fourth row, second option from the left). In the Depth box, enter 12 pt. Under Surface, click the button next to Material, and then under Standard click Warm Matte (second option from the left). On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate. Drag the duplicate picture to the right on the slide. Right-click the duplicate picture, and click Change Picture. In the Insert Picture dialog box, select a picture and click Insert.Select the first picture. On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate. Drag the duplicate picture to the left on the slide. Right-click the duplicate picture, and click Change Picture. In the Insert Picture dialog box, select a picture and click Insert.Select the picture on the left side of the slide. On the Home tab, in the bottom right corner of the Drawing group, click the Format Picture dialog box launcher. In the Format Picture dialog box, click 3-D Rotation in the left pane. In the 3-D Rotation pane, click the button next to Presets, and then under Perspective, click Perspective Heroic Extreme Right (third row, third option from the left).Under Picture Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Size tab, resize or crop the picture as needed so that under Size and rotate, the Height box is set to 3.8 and the Width box is set to 2.53. Resize the picture under Size and rotate by entering values into the Height and Width boxes. Crop the picture under Crop from by entering values into the Left, Right, Top, and Bottom boxes. Select the picture on the right side of the slide. On the Home tab, in the bottom right corner of the Drawing group, click the Format Picture dialog box launcher. In the Format Picture dialog box, click 3-D Rotation in the left pane. In the 3-D Rotation pane, click the button next to Presets, and then under Perspective, click Perspective Heroic Extreme Left (third row, second option from the left).Under Picture Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Size tab, resize or crop the picture as needed so that under Size and rotate, the Height box is set to 4.17 and the Width box is set to 2.78. Resize the picture under Size and rotate by entering values into the Height and Width boxes. Crop the picture under Crop from by entering values into the Left, Right, Top, and Bottom boxes.

To reproduce the background effects on this slide, do the following:Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Linear.Click the button next to Direction, and then click Linear Down (first row, second option from the left). In the Angle box, enter 90.Under Gradient stops, click Add or Remove until four stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops that you added as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 5% (sixth row, second option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 24%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 50% (sixth row, first option from the left).Select Stop 3 from the list, and then do the following:In the Stop position box, enter 35%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 50% (sixth row, first option from the left).Select Stop 4 from the list, and then do the following:In the Stop position box, enter 90%.Click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 5% (sixth row, second option from the left).

HTA en EmergenciasDr. Luis Leonardo Chacn PradoPicture triptych(Intermediate)

Tip: For best results with the effects on this slide, use pictures with a portrait (vertical) orientation.

To reproduce the picture effects on this slide, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank.On the Insert tab, in the Illustrations group, click Picture. In the Insert Picture dialog box, select a picture, and then click Insert. Select the picture. Under Picture Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Size tab, resize or crop the picture as needed so that under Size and rotate, the Height box is set to 3.5 and the Width box is set to 2.35. Resize the picture under Size and rotate by entering values into the Height and Width boxes. Crop the picture under Crop from by entering values into the Left, Right, Top, and Bottom boxes. On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align to Slide.Click Align Center.On the Home tab, in the bottom right corner of the Drawing group, click the Format Picture dialog box launcher. In the Format Picture dialog box, click Line Color in the left pane. In the Line Color pane, select Solid line, click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 25% (fourth row, second option from the left). Also in the Format Picture dialog box, click Line Style in the left pane, and then in the Line Style pane, in the Width box, enter 8 pt.Also in the Format Picture dialog box, click Shadow in the left pane. In the Shadow pane, click the button next to Presets, and then under Perspective, click Perspective Diagonal Upper Right (first row, second option from the left).Also in the Format Picture dialog box, click 3-D Format in the left pane, and then do the following in the 3-D Format pane:Under Bevel, click the button next to Top, and then under Bevel click Relaxed Inset (first row, second option from the left). Next to Top, in the Width box, enter 8 pt, and in the Height box, enter 6 pt. Under Depth, click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 25% (fourth row, second option from the left). In the Depth box, enter 12 pt. Under Surface, click the button next to Material, and then under Standard click Warm Matte (second option from the left). On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate. Drag the duplicate picture to the right on the slide. Right-click the duplicate picture, and click Change Picture. In the Insert Picture dialog box, select a picture and click Insert.Select the first picture. On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate. Drag the duplicate picture to the left on the slide. Right-click the duplicate picture, and click Change Picture. In the Insert Picture dialog box, select a picture and click Insert.Select the picture on the left side of the slide. On the Home tab, in the bottom right corner of the Drawing group, click the Format Picture dialog box launcher. In the Format Picture dialog box, click 3-D Rotation in the left pane. In the 3-D Rotation pane, click the button next to Presets, and then under Perspective, click Perspective Heroic Extreme Right (third row, third option from the left).Under Picture Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Size tab, resize or crop the picture as needed so that under Size and rotate, the Height box is set to 3.8 and the Width box is set to 2.53. Resize the picture under Size and rotate by entering values into the Height and Width boxes. Crop the picture under Crop from by entering values into the Left, Right, Top, and Bottom boxes. Select the picture on the right side of the slide. On the Home tab, in the bottom right corner of the Drawing group, click the Format Picture dialog box launcher. In the Format Picture dialog box, click 3-D Rotation in the left pane. In the 3-D Rotation pane, click the button next to Presets, and then under Perspective, click Perspective Heroic Extreme Left (third row, second option from the left).Under Picture Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Size tab, resize or crop the picture as needed so that under Size and rotate, the Height box is set to 4.17 and the Width box is set to 2.78. Resize the picture under Size and rotate by entering values into the Height and Width boxes. Crop the picture under Crop from by entering values into the Left, Right, Top, and Bottom boxes.

To reproduce the background effects on this slide, do the following:Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Linear.Click the button next to Direction, and then click Linear Down (first row, second option from the left). In the Angle box, enter 90.Under Gradient stops, click Add or Remove until four stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops that you added as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 5% (sixth row, second option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 24%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 50% (sixth row, first option from the left).Select Stop 3 from the list, and then do the following:In the Stop position box, enter 35%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 50% (sixth row, first option from the left).Select Stop 4 from the list, and then do the following:In the Stop position box, enter 90%.Click the button next to Color, and then under Theme Colors click Black, Text 1, Lighter 5% (sixth row, second option from the left).

TemasGeneralidadesDefinicionesConceptos tilesAbordajes especficosHTA AsxConsideracionesAlgoritmoMedicamentos (CCSS)HTA SintomticaCasos especficosAlgoritmosMedicamentos (CCSS)Referencias

Primero que nadaLos asistentes a una charla dificilmente prestan atencin por ms de una hora, incluso a los mejores oradores del mundo

Al salir de una conferencia, ya se olvidaron aproximadamente 50% de las cosas que se dijeron en la misma

Al cabo de una semana, solo 5% de lo que se dijo en la charla es retenido.

En este caso, aproximadamente una diapositivaTramadol (Tramal)El tramal es un opioide.

Los opioides pueden producir hipotensin 2 a liberacin de histamina.

La probabilidad de sufrir cualquier efecto adverso del tramal es 71%

EL TRAMAL NO DEBE UTILIZARSE COMO ANTIHIPERTENSIVO FINConsideraciones GeneralesConsideraciones Generales1 de cada 4 adultos es hipertensoDe esos, ms de la mitad son mayores de 60 aosA los 55 aos, el riesgo de ser hipertenso es 90%Del 100% de la poblacin hipertensa70% tiene Dx (es decir, 1 de cada 3 hipertensos deconoce serlo)60% estn siendo tratados35% alcanzan controlar bien su PA1 de cada 3 adultos de raza negra es hipertensoAtribuible a 6% de todas las muertes mundiales

Consideraciones Generales

Consideraciones GeneralesFisiopatologaSmartArt custom animation effects: vertical block list(Intermediate)

To reproduce the SmartArt effects on this slide, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank. On the Insert tab, in the Illustrations group, click SmartArt. In the Choose a SmartArt Graphic dialog box, in the left pane, click List. In the List pane, click Vertical Block List (fourth row, third option from the left), and then click OK to insert the graphic into the slide. To create a fourth row, do the following:Select the third block shape (the shape on the left side) at the bottom of the graphic, under SmartArt Tools, on the Design tab, in the Create Graphic group, click the arrow next to Add Shape, and select Add Shape After.To add a bulleted rectangle next to the fourth block shape, select the fourth block shape, and then under SmartArt Tools, on the Design tab, in the Create Graphic group, click Add Bullet.To enter numbers and text in the blocks and rectangles, select the graphic, and then click one of the arrows on the left border. In the Type your text here dialog box, enter text for each shape. (Note: In the example slide, the first-level text boxes contain 1, 2, 3, and 4. There should be only one second-level text box for each first-level box (delete the second bullet), and they contain First statement, Second statement, and so on.)

To reproduce the rectangle effects on this slide, do the following:Press and hold CTRL, and then select each of the rectangles (on the right side of the graphic).Under SmartArt Tools, on the Format tab, in the Shapes group, click the arrow to the right of Change Shape, and under Rectangles select Snip Diagonal Corner Rectangle (fifth option from the left).With the rectangles still selected, drag one of the left center adjustment handles 1 to the left to lengthen all four rectangles.With the rectangles still selected, on the Home tab, in the Font group, in the Font Size box, select 36, and in the Font Color list, under Theme Colors select White, Background 1 (first row, first option from the left). With the rectangles still selected, on the Home tab, in the bottom right corner of the Paragraph group, click the Paragraph dialog box launcher. In the Paragraph dialog box, under Indentation, do the following:In the Before Text box, enter 1.In the Special list, select Hanging.Next to the Special list, in the By box, enter 1.Select the SmartArt graphic, and then under SmartArt Tools, on the Design tab, in the SmartArt Styles group, click More Styles, and under 3-D select Polished Effect (first option from the left). Select the first rectangle from the top (First statement in the example slide), and on the Home tab, in the Drawing group, click the arrow to the right of Shape Fill, and under Theme Colors select Red, Accent 2 (first row, sixth option from the left).Select the second rectangle from the top (Second statement in the example slide), and on the Home tab, in the Drawing group, click the arrow to the right of Shape Fill, and under Theme Colors select Olive Green, Accent 3 (first row, seventh option from the right).Select the third rectangle from the top (Third statement in the example slide), and on the Home tab, in the Drawing group, click the arrow to the right of Shape Fill, and under Theme Colors select Purple, Accent 4 (first row, eighth option from the left). Select the fourth rectangle from the top (Fourth statement in the example slide), and on the Home tab, in the Drawing group, click the arrow to the right of Shape Fill, and under Theme Colors select Orange, Accent 6 (first row, tenth option from the left).

To reproduce the circles on this slide, do the following:Press and hold CTRL, and then select the four block shapes (the shapes on the left side) in the SmartArt graphic, and then under SmartArt Tools, on the Format tab, in the Shapes group, click the arrow to the right of Change Shape, and under Basic Shapes select Oval (first row, first option from the left). On the slide, drag one of the top right adjustment handles to the left to change the ovals into circles and to decrease their size.Also with the four circles selected, drag the circles until they cover the bullet on the rectangles, and then on the Home tab, in the Font group, in the Font Color list, under Theme Colors select White, Background 1, Darker 50% (sixth row, first option from the left). Also on the Home tab, in the bottom right corner of the Drawing group, click the Format Shape dialog box launcher. In the Format Shape dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.In the Direction list, select From Center (third option from the left).Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops that you added as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors select White, Background 1 (first row, first option from the left). Select Stop 2 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and then under Theme Colors select White, Background 2, Darker 25% (fourth row, first option from the left).

To reproduce the animation effects on this slide, do the following:On the Animations tab, in the Animations group, click Custom Animation. On the slide, select the SmartArt graphic, and then in the Custom Animation task pane, do the following:Click Add Effect, point to Entrance, and select More Effects. In the Add Entrance Effect dialog box, under Subtle select Fade.With the SmartArt graphic still selected, click Add Effect, point to Motion Paths, and select Right.On the slide, right-click the motion path and select Reverse Path Direction. In the Custom Animation task pane, do the following:Press and hold CTRL, and select the two effects in the task pane. Click the arrow to the right of the selected effects and select Effect Options. In the Effects Options dialog box, do the following:On the Timing tab, in the Speed list, select Fast. On the SmartArt Animation tab, in the Group graphic list, select One by one.Click the double arrows under the two effects to show all the effects for all the shapes (16 effects).Press and hold CTRL, select all of the effects, and then under Modify selected effects, in the Start list, select With Previous.Press and hold CTRL, select the first, third, fifth, and seventh effects (fade entrance effects), and then do the following:Click Change, point to Entrance, and select More Effects. In the Change Entrance Effect dialog box, under Moderate, select Grow & Turn.Under Modify: Grow & Turn, in the Start list, select After Previous.Press and hold CTRL, and select the ninth, 11th, 13th, and 15th effects (right motion paths). Click the arrow next to one of the selected effects, and then click Remove.Drag the ninth effect (right motion path) until it is third in the list of effects.Drag the 10th effect (right motion path), until it is sixth in the list of effects.Drag the 11th effect (right motion path), until it is ninth in the list of effects.

To reproduce the background effects on this slide, do the following:Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.Click the button next to Direction, and then click From Center (third option from the left). Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops that you added as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 33%.Click the button next to Color, and then under Theme Colors select White, Background 1 (first row, first option from the left). Select Stop 2 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and then under Theme Colors select White, Background 1, Darker 25% (fourth row, first option from the left).

Consideraciones Generales

DefinicionesPrimaria vs Secundaria

HTA SecundariaHTA en Sala de Emergencias

Urgencia vs EmergenciaUrgencia (80%)No hay peligro de muerteSin dao agudo a organo blanco (puede haber crnico)Control PA en dasManejo aumbulatorioMedicacin oral de titulacin rpidaEmergencia (20%)Vida corre peligroDao agudo a rgano blancoControl de la PA en minutos u horasManejo IntrahospitalarioMedicacin ParenteralOJO!La clnica mandaFamoso 180/120

Emergencia:Manejo ADECUADO de la enfermedadNo confundir con bajar rpido la presin

La principal causa de urgencias hipertensivas es abandono del Tx crnico

Debo corregir en horas lo que el paciente ha venido arrastrando por semanas?Emergencias HipertensivasRetinopata Hipertensiva (KW-4)CerebrovascularHSAHICECVEncefalopata HipertensivaCardiacoDiseccin de AortaICC + EAPSCAHTA severa pos Bypass CoronarioRenalIRAGMN agudaCrisis Renal x ColagenopataEmbarazoEclampsiaHELLPQuirrgicoHipertensin severa :Preoperatoria de ciruga urgentePosoperatoria+ sangrado por sitios de suturaCrisis simpticas Cocana,FeocromocitomaIMAO + dieta rica en tiraminaS/S abrupta de medicacinHTA severa ms quemaduras extensasHTA + Epistaxis

Groucho: Por qu y cmo ha llegado usted a tener veinte hijos en su matrimonio? Concursante: Amo a mi marido.

Groucho: Seora, a m tambin me gusta mucho mi puro, pero de vez en cuando me lo saco de la boca.Abordajes especficosUrgencia HipertensivaLa rpidez exacta para alcanzar PA meta es controversial.

Lo que est claro es que, en ausencia de sntomas, debe hacerse una reduccin gradual.

Existen gran variedad de modalidades teraputicas para este finNO USAR MEDICACION SUBLINGUAL EN PX ASX (Nifedipina/NTG)

Est demostrado que en muchos casos la PA disminuye espontneamente reposando en un cuarto silenciosoComo el de la casa!Darle reposo a un paciente en SEM PA 10 a 20 mmHgCurva de autoregulacin de PA

Urgencia HipertensivaNo existe evidencia de beneficios de una reduccin rpida de la PA en HTA severa asintomtica

DE HECHO, puede inducirse isquemia / infarto cerebral / cardiaco si la PA cae debajo del rango de autoregulacinEjemplo: nifedipina sublingual.

Meta: PA < 160/100 en horas o das (Individualizar)

Urgencia HipertensivaHTA previamente tratadaAumentar la dosis de tx oral, o adicionar un 2do.

Restituir la medicacin en pacientes con mala adherencia

Adicionar diurtico y estimular la dieta hiposdica.HTA no tratadaEstablecer riesgos:De persistir hipertenso

De que se complique si permanece hipertenso ms tiempo

De que haga isquemia o infarto por reduccin rpida de su PAUrgencia HipertensivaLa HTA severa asintomtica por lo general se maneja en SEMExcluir dao a rgano blanco

En la gran mayora de los casos, es seguro manejarla de manera ambulatoria

Valorar hospitalizacin en pacientes con comorbilidades importantes y que difcilmente van a ir a cita de control.

Observar unas horas y documentar descenso en PA (y confirmar que efectivamente son asintomticos)Egreso y seguimiento en EBAIS

Emergencias HipertensivasECV77% vienen con HTABajar la PA de forma abrupta empeora pronstico neurolgicoSi PA > 220/120: reducir la PAM a < 140 mmHgEn la CCSS: Nitroprusiato IVCandidatos a rTPA: < 185/110 Recuerde: PPC = PAM PICHTA es respuesta fisiolgicaConcepto de rea de penumbraEmergencias HipertensivasICC/EAPEs por RVP ms que por aumento de volemiaExcepto en IRC / iatrogenia con fluidoterapiaDosis altas de Lasix = NO!Dosis altas de NTG IV = SI!cPAP mejor que diurtico en EAP

Emergencias HipertensivasEncefalopata hipertensivaHTA + cefalea insidiosa + confusin + convulsiones + alteraciones visuales + vmitoNo hay dficit neurolgico focalA diferencia del ECV, sntomas se controlan con reduccin rpida de PA en 24 48 horasHallazgo en TAC: leucoencefalopata occipital reversibleNO ES UNA FORMA DE PRESENTACION DE ECVEmergencias HipertensivasHIC/HSAPPC = PAM-PICPA meta: no menos de 180/90Nimodipina: disminuye vasoespasmo secundario a irritacin de parnquima cerebral

Emergencias HipertensivasDiseccin de AortaGC = FC x VSZona de principal agresin: aorta ascendenteIrrigacin coronaria?Sangrado = FC = GC = empeora diseccinBB es prioridad La nica que requiere normalizar la PA inmediatamente

Emergencias HipertensivasDiseccin de AortaDolor torcico o dorso severo con o sin irradiacin a extremidad/abdomen.Regurgitacin articaPulso carotideo palpable asimtricoDiferencia de PA entre ambos brazos.Derrame PericrdicoRoce pericrdicoHistoria de FRAlteracin o dficit neurolgico

Emergencias HipertensivasCrisis simpticaNo dar BB: tormenta alfa adrenrgica!

Cocana BZD IV las dosis que sea necesariaNTG/NTP

Feocromocitoma = Fentolamina

Preguntas o Comentarios?