Hypertensive Emergencies - Dr. Godfrey

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

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