Hypertensive crisis
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Hypertensive emergencies require rapid blood pressure reduction to prevent target organ damage, while hypertensive urgencies only require gradual reduction over 24 hours without end organ involvement. The case study describes a patient presenting with acute pulmonary edema secondary to hypertensive emergency and acute kidney injury. He was intubated and given intravenous nitrates, frusemide and morphine to rapidly reduce blood pressure and relieve pulmonary congestion over several hours.
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Hypertensive crisis
- 2. Outline.. Definition Approach in ED Management Case study
- 4. Definition.. Hypertension is defined as persistent elevation of systolic BP of ≥ 140mmHg and/or diastolic BP of ≥ 90 mmHg CPG Management of hypertension. 4th ed. 2013
- 5. Definition.. Severe hypertension is defined as persistent elevated SBP >180 mmHg and/or DBP >110 mmHg Further classified into: (a) Asymptomatic (b) hypertensive urgencies (c) hypertensive emergencies CPG Management of hypertension. 4th ed. 2013 Hypertensive crisis
- 6. Hypertensive Emergency.. Persistent elevated SBP >180 mmHg and/or DBP >110 mmHg with target organ damage/complication It is the target organ dysfunction rather than the absolute blood pressure level pre se Situations that require immediate blood pressure reduction to prevent or limit target organ damage CPG Management of hypertension. 4th ed. 2013 Shirley O. & Peter M. Emergency Medicine. 2nd ed. 2015 Sixth Report of the JNC on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 1997
- 7. The rate of rise of the of the blood pressure is more important rather than the absolute level of BP itself
- 8. Hypertensive Urgency.. Persistent elevated SBP >180 mmHg and/or DBP >110 mmHg with no overt acute target organ damage/complication Clinical scenarios with markedly elevated blood pressure without obvious end-organ dysfunction CPG Management of hypertension. 4th ed. 2013 Shirley O. & Peter M. Emergency Medicine. 2nd ed. 2015
- 11. Clinical presentation.. 1. Incidental finding 2. Non-specific symptoms like headache, dizziness, lethargy 3. Symptoms and signs of acute target organ damage. Eg. acute heart failure, acute coronary syndromes, acute renal failure, dissecting aneurysm, subarachnoid haemorrhage and hypertensive encephalopathy.
- 12. Approach in ED… Is the BP reading correct? Repeat using manual sphygmomanometer Correct cuff size Check the other arm Recheck about 1 hour later Thorough history Compliancy to medication
- 14. Approach in ED… Is it a hypertensive emergency? Look for evidence of end organ damage Neurological examination : altered mental status, neurological deficit Fundoscopy : papilloedema, haemorrage CVS : APO, Aortic dissection
- 15. Approach in ED… Bedside investigation ECG UPT
- 16. Approach in ED… Lab investigation FBC RP Urine FEME LFP/ Coag CE/ trop T
- 17. Approach in ED… Radiological ix CXR CT scan (altered mental status)
- 18. Management ABC All patient with hypertensive emergency should be managed in RED ZONE Hypertensive urgency may be managed in the YELLOW ZONE Aim: to control BP without compromising circulation to the end organs
- 19. Hypertensive urgency Initial treatment should aim for about 25% reduction in BP over 24 hours but not lower than 160/90 mmHg. Oral drugs are proven to be effective. There is no role for intravenous BP lowering drugs. Combination therapy is necessary.
- 21. Hypertensive Emergency The BP needs to be reduced rapidly. It is suggested that the BP be reduced by 25% depending on clinical scenario over 3 to 12 hours but not lower than 160/90 mmHg. This is best achieved with parenteral drugs.
- 22. Hypertensive Emergency The specific management will depend on the end- organ systems that affected by the BP Aortic Dissection Rapidly reduce SBP to 100-120 mmHg within 5-10 minutes Beta blocker, IV morphine Acute ischaemic stroke Anti-HPT is not routinely indicated SBP > 220mmHg or DBP >120mmHg
- 23. Hypertensive Emergency Pre – clampsia MgSO4 hydralazine, labetolol, methyldopa Acute left ventricular failure/ APO IV GTN
- 24. Case Study.. 44 y/o Indonesian gentleman Non-smoker Underlying: HPT – not on proper follow/up – not on any medication Presented with: 1) SOB x 3/7 worsening today 2) cough x 3/7 yellowish sputum 3) fever x 3/7 low grade fever on and off Otherwise: no PND/ orthopnea / lower limbs swelling no chest pain
- 25. Examination GCS 15/15 (E4V5M6) vital sign: BP: 253/147(174) PR: 117 RR: 30 SPO2: 97% Lungs: Generalized crepitations
- 26. Investigation ABG: ph 7.11, pco2 27, po2 103, lac 2.4, hco3 8.6 FBC : hb 5.9 , hct 17.7, plt 354, wcc18.9 RP : urea 46.4, Na 131, k 5.1, creatinine1787
- 28. Diagnosis 1) APO secondary to HPT emergency 2) Cover for CAP (curb 3) 3) Severe metabolic acidosis secondary to acute on CKD (newly diagnosed)
- 29. Management Decided for intubation due to impending respiratory collapse While intubated noted frothy sputum
- 30. Management IVI GTN 5mcg/min IV frusemide 40mg stat Subsequently, Bp 220/135 IVI GTN increase to 15mcg/ min Admit medical ward
- 31. APO management – Management of heart failure CPG 1) Oxygen – aim of achieving spo2 > 95%. Elective ventilation using non invasive positive pressure ventilation (CPAP or BiPAP) should be considered early. Should the oxygen saturation be inadequate or the patient develop respiratory muscle fatigue, then intubation is necessary.
- 32. 2) Nitrates - are indicated as first line therapy. Reduce preload and afterload Sublingually or intravenously. The i.v. route is more effective and preferable. Studies have shown that the combination of i.v. nitrate and low dose frusemide is more efficacious than high dose diuretic treatment alone.
- 33. IVI GTN preparation 1 amp = 50mg in 10 mls 1) 50mg dilute in 50cc 0.3ml/hr = 5mcg/min 2) 30mg dilute in 50cc 1ml/hr = 10mcg/min
- 34. 3) Frusemide – Intravenous (i.v.) frusemide 40 – 100mg. Administration of a loading dose followed by a continuous infusion. The dose should be titrated according to clinical response and renal function.
- 35. 4) Morphine – i.v. 3 – 5 mg bolus (repeated if necessary, up to a total maximum of 10mg). It reduces pulmonary venous congestion and sympathetic drive. It is most useful in patients who are dyspnoeic and restless.
- 37. Take home message… Do not reduce BP rapidly in asymptomatic severe hypertension. Treat hypertensive urgencies with combination oral therapy targeting BP to reduce by around 25% within 24 hours. Treat hypertensive emergencies with intravenous drugs targeting BP to reduce by around 25% within 3 to 12 hours.
- 38. References… CPG Management of hypertension. 4th ed. 2013 Shirley O. & Peter M. Emergency Medicine. 2nd ed. 2015 CPG Management of heart failure. 2nd ed. 2007