HYPERTENSIVE EMERGENCIES TREATMENT

ABHISHEK JHA

A Hypertensive Emergency is a sudden spike in blood pressure to 180/120 or higher, and is a medical emergency. It could lead to organ damage or be life-threatening.

A hypertensive crisis is divided into two categories: urgent and emergency. In an urgent hypertensive crisis, blood pressure is extremely high, but no organ damage. In an emergency hypertensive crisis, blood pressure is extremely high and has caused organs damage. An emergency hypertensive crisis is associated with life-threatening complications

Causes of a hypertensive emergency include:

Forgetting to take your blood pressure medication Stroke Heart attack Heart failure Kidney failure Rupture of your body's main artery (aorta) Interaction between medications Convulsions during pregnancy (eclampsia)

Signs and symptoms of a hypertensive crisis that may be life–threatening may include:

Severe chest pain Severe headache, accompanied by confusion and blurred vision Nausea and vomiting Severe anxiety Shortness of breath Seizures

Unresponsiveness

PREFERRED PARENTERAL DRUGS FOR SELECTED HYERTENSIVE EMERGENCIES

DOC FOR HYPERTENSIVE ENCEPHALOPATHY = 1. SODIUM NITROPRUSSIDE 2. NICARDIPINE 3. LABETALOL

DOC FOR MALIGNANT HYPERTENSION (WHEN IV THERAPY INDICATED) = 1. LABETALOL2. NICARDIPINE3. SODIUM NITROPRUSSIDE4. ENALAPRILAT

DOC FOR STROKE = 1. NICARDIPINE 2. LABETALOL 3. NITROPRUSSIDE

DOC FOR MYOCARDIAL INFARCTION/UNSTABLE ANGINA = 1. ESMOLOL 2. NITROGLYCERIN 3. NICARDIPINE 4. LABETALOL

DOC FOR ACUTE LEFT VENTRICLE FAILURE = 1. NITROGLYCERIN 2. LOOP DIURETICES 3. ENALAPRILAT

DOC FOR AORTIC DISSECTION = 1. NITROPRUSSIDE 2. ESMOLOL 3. LABETALOL

DOC FOR ADRENERGIC CRISIS/PHEOCHROMOCYTOMA = 1. NITROPRUSSIDE 2.

PHENTOLAMINE

DOC FOR POSTOPERATIVE HYPERTENSION = 1. NITROGLYCERIN 2. NITROPRUSSIDE 3. NICARDIPINE 4. LABETALOL

DOC FOR PREECLAMPSIA/ECLAMPSIA OF PREGNANCY= 1. HYDRALAZINE 2. LABETALOL 3. NICARDIPINE

NON-PHARMACOLOGICAL TREATMENT Considered in cases of resistant malignant hypertension due to end stage renal failure, such as: surgical nephrectomy, laparoscopic nephrectomy and renal artery embolization in cases of anesthesia risk.

Controlled bloodletting is an effective salvage therapy in the interim when nitroprusside is unavailable, and aggressive oral therapy has not yet taken effect.

BLOOD PRESSURE should be lowered smoothly, not too abruptly. The initial goal in hypertensive emergencies is to reduce the mean arterial blood pressure by no more than 25% (within minutes to 1 or 2 hours), accomplished IV Nitroprusside and then toward a level of 160/100 mmHg within a total of 2–6 hours. Excessive reduction in blood pressure can precipitate coronary, cerebral, or renal ischemia and infarction.

NITROPRUSSIDE = Acts as a drug by releasing nitric oxide; it belongs to the class of NO-releasing drugs. This drug is used as a vasodilator to reduce blood pressure.INTRAVENOUS DOSE: initial 0.3(ug/kg)/min, usual 2-4(ug/kg)/min, max 10(ug/kg)/min..Due to its cyanogenic nature, overdose may be particularly dangerous. Treatment of sodium nitroprusside overdose includes the following:

Discontinuing sodium nitroprusside administrationbuffering the cyanide by using sodium nitrite to convert hemoglobin to methaemoglobin as much as the patient can safely tolerate.Infusing sodium thiosulfate to convert the cyanide to thiocyanate.

NICARDIPINE = Dihydropyridine calcium-channel blocking agent used for the treatment of vascular disorders. More selective for cerebral and coronary blood vesselsIntravenous Dose: initial 5mg/h; titrate by 2.5 mg/h at 5-15 min intervals, max 15mg/h

LABETALOL: Cause postural hypotension, there is a substantial drop in blood pressure when standing up. In short term, acute situations, labetalol decreases BP by decreasing systemic vascular resistance with little effect on stroke volume, heart rate and cardiac output. During long term use, labetalol can reduce heart rate during exercise while maintaining cardiac output by an increase in stroke volumeIntravenous Dose: 2mg/min up to 300mg/min or 20mg over 2 min, 40-80mg at 10 min intervals up to 300mg total.

NITROGLYCERIN: Initial 5ug/min then titrate by 5ug/min at 3-5 min intervals; if no response is seen at 20ug/min, incremental increase of 10-20ug/min may be used.

HYDRALAZINE: 10-50mg at 30 min intervals.

ENALAPRILAT: Usual 0.62-1.25mg over 5 min every 6-8hr; max 5mg/dose.

ESMOLOL: Initial 80-500ug/kg over 1 min, thn 50-300(ug/kg)/min. PHENTOLAMINE: 5-15 mg bolus.