Core Concepts from Hypertensive Emergencies
Trick or Treat?
 
Definitions:
Asx HTN <220/120 without complaints
HTN urgency >220/120 w/o end organ damage
HTN emergency >220/120 + end organ damage
 
When to treat asx HTN?
If BP >165/105 + Cr >2, start two agents
or >220/>120 without any dysfunction, two agents
If  140-165: Controversial, but at the very least, tell the pt and Fast-track them
*Social intervention*
 
Rx:
No comorbidities:
black, all ages: CCB or TZD
white, <60 ACEI or ARB
white, >60, CCB or TZD
 
HTN
+ DM: ACEI or ARB
+ CKD: ACEI or ARB
+ CAD: BB + ACEI or ARB
+ CVA: ACEI or ARB
+ CHF: ACEI or ARB + BB + diuretic
 
HTN Urgency:
don't need to treat in the ED.
Do at least an EKG and check Cr. Plus fundoscopy and lytes
 
HTN Emergencies-
Aortic Dissection
Make the Dx and STOP progression
Listen for AI murmur and assess for acute heart failure
If no murmur and no failure, proceed with IV BB
Safe: morphine + nicardipine
 
Hypertensive Encephalopathy
Decrease MAP 25% in 8 hours
use comorbid appropriate therapy
Give something IV and admit
 
ICH
Let it ride unless >220/110
generally avoid nitroprusside with neurologic emergencies
Pick anything else. We like labetalol
 
Acute Ischemic Stroke
If tPA candidate, treat if BP >185/110
Otherwise, protect the penumbra
 
SAH
No good guidelines
MAP<130
Lookout for complications in the first 24 hours
 
ACS
Treat if >160/>110
No lytics if >185/>110
Use NTG (paste, SL, IV), then BB if needed
 
ACHFE
the higher the initial BP, the better chance of survival
nitro + enalaprilat +/- lasix if they have evidence of fluid overload
 
Cocaine
ASA + lorazepam
backup: NTG, CCB or phentolamine
BB dogma is lifting
 
Eclampsia
IV mag + labetalol or hydralazine

ACEP 2013 Guidelines

DO’s

1. Take repeat blood pressures during your patient’s stay in the ED
2. Fast track patients with severely elevated blood pressures (>180/110) to a PCP
3. Start a patient on a maintenance oral antihypertensive if BP severely elevated
    a. BUT REMEMBER!
            i. Get a BMP
            ii.Think about their comorbidities

DONT’s

1. HARMFUL! Do NOT give acute antihypertensives (i.e. clonidine, IV drugs) to asymptomatic patients.
2. Send home patient’s WITHOUT any follow up

Limitations of ACEP 2013 Guidelines: Do NOT apply these guidelines to patients who have symptoms that may be indicative of a hypertensive emergency, pregnant patients, or patients with end stage renal disease.