Presentation on theme: "Management of Hypertension and Hypotension in the Emergency Department"— Presentation transcript:
1 Management of Hypertension and Hypotension in the Emergency Department
2 HypertensionHow do we manage Hypertension in the ER??
3 Hypertension Management in the ED Annual Census = 78,000 patientsApproximately 215 patients per day40 to 50% have elevated BP readings upon admission to the EDThat is roughly 39,000 patients/yr with elevated blood pressure readings in the ER.
7 Hypertensive Emergency - A relative increase in blood pressure from baseline combined with Target Organ Dysfunction (TOD)No Defined Pressure MeasurementTarget Organ Damage is evidentAlso known as Hypertensive Crisis or Malignant HypertensionThe MOST Serious form of hypertension
9 Target Organ Dysfunction Evidence of Damage or Injury to “Target Organs” such as the Heart, Brain, Lungs, Kidneys, or Aorta.
10 Examples of Target Organ Dysfunction Acute MI/ Unstable AnginaCVAICH / Subarachnoid HemorrhageCHFAortic DissectionAcute Renal FailureHypertensive Encephalopathy
11 How do we determine ifTarget Organ Dysfunctionis present?
12 Evaluation for Target Organ Dysfunction EKG: (Evaluation for ST elevation or depression, new T-wave inversions, LVH, or new Left BBB)CXR: (CHF/pulmonary edema, cardiomegaly, widened mediastinum)UA or urine dip: (looking for proteinuria, red cells, or red cell casts)Chem 8: (elevated BUN/CR indicating acute renal insufficiency or failure, look for other etiologies causing mental status changes, like hypoglycemia)Neurological Exam: (Evaluate for lateralizing signs and symptoms)Funduscopic Exam: (looking for papilledema or hemorrhages)CT Head: (only if neurological findings are suspicious for acute CVA)
13 Diagnosis and Management ofHypertensive Emergency
14 Hypertensive Encephalopathy Pathophysiology:- Loss of Cerebral Autoregulation of blood flow resulting in hyperperfusion of the brain, loss of integrity of the blood brain barrier, and vascular necrosis.Loss of Autoregulation occurs at a constant cerebral blood flow of above MAP 150 to 160 mmHg.Acute OnsetReversible
15 Hypertensive Encephalopathy Symptoms:Headache, Nausea/Vomiting, Lethargy,Confusion, Lateralizing neurological symptomsthat are not often in an anatomical distribution.Signs:Papilledema, Retinal HemorrhagesDecreased level of consciousness, ComaFocal neurological findings
16 Management of Hypertensive Encephalopathy Reduce Mean Arterial Pressure (MAP) by 20 to 25% (T.397) and do not exceed this within first 30 to 60 min.Rosen recommends reduction of 30 to 40% (R.1759)MAP= 1/3(SBP-DBP) + DBPTreatment Reduces vasospasm that occurs at these high pressuresAvoid excessive BP reduction to prevent hypoperfusion of the brain and further cerebral ischemia
17 Management of Hypertensive Encephalopathy - Nitroprusside is the agent of choice (T.397) and (R.1759)- Nitroglycerin and Labetalol have been used successfully, but have not replaced Nitroprusside
19 Ischemic CVA Pathophysiology: Elevated Blood Pressure can be the cause of the central nervous system event, OR, it may be a normal physiologic response (Cushing’s Reflex)
20 Ischemic CVA Management Elevated blood pressure is usually a physiologic response to the stroke itself and NOT the immediate causeThis elevation of blood pressure maintains cerebral perfusion to viable but edematous tissue surrounding the ischemic area.Most embolic or thrombotic strokes do NOT have substantial BP elevations and do not need aggressive therapy
21 Ischemic CVA Management Management: VERY CONTROVERSIAL!Recent Trends leans towards NOT treating hypertension in the presence of a Cerebrovascular Accident (thrombotic or embolic) unless Diastolic Blood Pressure exceeds 140mmHg.
22 Ischemic CVA Management Tintinelli: Favors lowering MAP (mean arterial pressure) by 20%.Recommends IV Labetalol in small doses of 5mg increments IF Diastolic Blood Pressure is higher than 140 mmHg.(T. 398)
23 Ischemic CVA Managment Rosen: In most cases, recommends no treatment of Hypertension in CVA patients.(p. 1760).- However, the author does recommend treating HTN if diastolic blood pressure is greater than 140 mmHg.
26 Hemorrhagic CVA Management Hypertension associated with hemorrhagic stroke is usually transitory and the result of increased intracranial pressure and irritation of the Autonomic Nervous System
27 Hemorrhagic CVA Management Hemorrhagic CVA’s commonly results in a profound reactive rise in blood pressureManagement is CONTROVERSIAL.Subarachnoid Hemorrhage: oral nimodipine (nimotop) 60mg po q 4 hours to reverse vasospasm. (T.398)Nicardipine: 2mg IV boluses followed by an IV infusion of 4 to 15 mg/hr is used by some to treat Subarachnoid Hemorrhage. (T.398)
31 CHF / Pulmonary Edema Management in the ED Nitroprusside or IV Nitroglycerin (T. 398)Rosen: May start with Nitroglycerin, but Nitroprusside is agent of choice if Pulmonary Edema is present. (R. 1760)Attempt treatment of CHF initially with standard agents (Lasix,sublingual NTG, morphine), as these often lower blood pressure, but resort to Nitroprusside if necessary (R. 1761)
34 Acute Coronary Syndrome / Acute MI Symptoms:Chest Pain, Nausea / Vomiting, Diaphoresis,Shortness of BreathSigns:Congestive Heart Failure Signs,S4 Gallop(due to decreased ventricular compliance)Few physical findings in many patientsClinical History is very Important
35 Acute Coronary Syndrome/ Acute MI Immediate Blood Pressure reduction is indicated to prevent Myocardial DamageNo specific Defined BP targetTailor treatment to symptom relief(T. 398)
36 Acute Coronary Syndrome / Acute MI Management:Nitroglycerin IV or Sublingual (T. 398)Nitroprusside (T. 398)Beta Blockers (Esmolol,Lopressor) (T )Nitroglycerin is Drug of Choice (R. 1761)
38 Dissection of Thoracic Aorta Pathophysiology:- Atherosclerotic Vascular Disease, Chronic Hypertension, increased shearing force on the thoracic aorta, leading to intimal tear.- 50% begin in ascending aorta- 30% at aortic arch- 20% in descending aorta (R )
39 Dissection of Thoracic Aorta Symptoms:Chest pain radiating to the back (classic presentation)Neurological Symptoms (carotid artery dissection)Angina (coronary artery dissection)Shortness of breath (aortic insufficiency, cardiac tamponade)Signs:- Differential Blood Pressure (in UE)Bruit (interscapular)Neurological DeficitsAcute Cardiac Tamponade (rare)
40 Dissection of Thoracic Aorta Management:Medications with negative inotropic effects (beta-blockers) MUST be given FIRST. (reduces shearing force)Vasodilators (nitroprusside) may be added for further antihypertensive treatment after administration of a negative inotropic agent.
41 Dissection of Thoracic Aorta Optimal Blood Pressure in these patients is undefined and must be tailored for each patient, however,SBP of mmHg may be a intial starting point. (T.408)
43 Acute Renal Failure Pathophysiology: Hypertensive Glomerulonephropathy, Acute Tubular Necrosis (ATN)- Worsening renal function in the setting of severe hypertension with elevation of BUN/CR, proteinuria, or the presence of red cells and red cell casts in the urine.
44 Acute Renal Failure Symptoms: Signs: - Many times there are few actual symptomsFacial or Peripheral Edema due to fluid overload or proteinuria may be present, shortness of breathSigns:Few findings unless edematousPulmonary Edema
45 Acute Renal Failure Management: Nitroprusside is agent of choice (T.398)Dialysis (as needed)Rosen: Lasix to enhance Sodium excretion; Also recommends Nitroprusside or Nifedipine (R.1761)Nitroglycerin is also a good agent in this setting since it is hepatically metabolized and gastrointestinally excreted.
51 Toxemia of Pregnancy Pathophysiology: Systemic arterial vasoconstriction (including placental, leading to decreased uterine blood flow).Defined as SBP = 140/90 mmHg or greater, OR a 20 mmHg rise in SBP or mmHg rise in DBP from baseline and evidence of HELLP Syndrome
52 Toxemia of Pregnancy Symptoms: Lower extremity swelling, headache, confusion, seizures, comaSigns:Edema, hyperreflexia, elevation of blood pressure related to baseline BP prior to pregnancy (elevation may be mild 125/75)
53 Toxemia of Pregnancy Management: IV Magnesium Sulfate, Hydralazine. May also use nifedipine or labetalol (R.1762)Delivery of Fetus is definitive treatment of pre-eclampsia
54 Summary of Medications used for Hypertensive Emergencies - Intravenous Nitroglycerin:Start at 0.2 to 0.4 mcg/kg/min (10 to 30 mcg/min) and rapidly increase in 5 to10 mcg/min increments. Titrate to BP and symptomatic improvement. (T.369)- Nitroprusside:Start 0.3 mcg/kg/min and titrate up every 5 to 10 minutes based on BP and clinical response. (T.369)- Esmolol: 500 mcg/kg initial bolus over 1 minute, then start infusion at 50 to 150 mcg/kg/min (T.408)- Metoprolol (Lopressor): 5mg IV every 2 minutes for a total of 3 doses, then start infusion at 2 to 5 mg/hr. (T.408)
55 Summary of Medications used for Hypertensive Emergencies - Labetalol: 20mg IV initial dose, with repeat doses of 40mg to 80mg every 10 minutes to reach desired effect or max dose 300mg. (T. 408)Nicardipine: 2mg IV boluses followed by an IV infusion of 4 to 15 mg/hrMagnesium Sulfate IV: 4 to 6 grams over 15 minutes, followed by IV infusion of 1 to 2 grams/hourHydralazine: 10 to 20mg IV
57 Hypertensive Urgency- A relative increase in blood pressure from baseline WITHOUT current evidence of TOD, but potential of progression to TOD is HIGH.- Increased likelihood when pre-existing conditions are present(renal insufficiency, CAD, CHF)
58 Hypertensive UrgencyCurrent recommendation is the gradual reduction of blood pressure within 24 to 48 hours by using oral antihypertensive agentsNon-compliance is a common cause, therefore, restarting a current regimen of blood pressure medication is appropriateMaking needed changes to current blood pressure medication regimens is also appropriateFollow-up within 24 hours should be arranged with Primary Care Physician
59 Oral Regimens for Treatment of Hypertensive Urgency in the ED (Tintinelli pg. 402)Clonidine: 0.1 to 0.2mg PO, repeat 0.1mg q hour to desired BP reduction or max of 0.7mg.Labetalol: 200 to 400mg PO, repeat every 2 to 3 hoursCaptopril: 25mg POLosartan: 50mg PO
61 Acute Hypertensive Episode Elevation of Blood Pressure relative to baseline, but WITHOUT evidence of acute OR impending Target Organ Dysfunction (TOD)
62 Management of Acute Hypertensive Episode Paucity of evidence that acute intervention in ED is warranted for Hypertensive EpisodeComplications can occur in acute treatment of patients with chronically elevated blood pressureIf HTN is newly diagnosed in the ER, patients should be referred to Primary Care physician for evaluation and initiation of therapy within 24 to 48 hoursAgain, restarting prior blood pressure medication regimens or adjusting doses is appropriate for patients with previously diagnosed hypertension.
64 Treatment of Transient Hypertension Transient HTN occurs in association with other conditions like anxiety, alcohol withdrawal syndromes, toxicological substances, and sudden cessation of medications)Treatment is aimed at underlying cause“White-Coat Hypertension”Single encounter in ED does not warrant diagnosis of HTN or treatment of HTNFollow-up with Primary Care Physician
68 Hypotension/Shock Goals of Management 1. Determine Cause:- Usually very apparent- Can be subtle- No single Vital Sign that is diagnostic of Shock- Initial Therapy guided by clinical findings
69 Management of Hypotension/Shock 2. Evaluate Signs and Symptoms:- Tachycardia- Decreased Urine Output- Cool, Mottled Skin- Cyanosis- Confusion
70 Hypotension/Shock Goals of Resuscitation ABC’s:A- Secure Airway (intubate if needed)B- Insure oxygenation and ventillationC- Provide Hemodynamic Stabilization (correction of hypotension based on etiology)
71 Resuscitation Initiate Fluid Therapy: 0.25 to 0.5 Liters of Normal Saline (NS) or similar isotonic crystalloid should be administered every 5 to 10 minutes as needed for correction of hypotension
72 Rapid Fluid Administration It is not unusual for a patient to require 4 to 6 Liters of fluid in the initial phase of resuscitation.
73 Goal of Fluid Resusciation Stabilization of pt’s mentationImprovement in Blood PressureReduction of Pulse RateImproved Skin PerfusionUrine Output > 30ml per hour
74 Inotropic SupportIf NO response to initial fluid infusion of 3 to 4 L is noted, OR if there are signs of fluid overload (pulmonary edema), Inotropic agents should be started.
75 Inotropic AgentsDopamine: Start infusion at 5 mcg/kg/min and titrate up to 20 mcg/kg/min in order to achieve desired BPIndicated for reversing hypotension related to AMI, trauma, sepsis, heart failure, and renal failure when fluid resuscitation is unsuccessful or not appropriate (T. 212)
76 Inotropic AgentsDobutamine: Dosage range is 2 to 20 mcg/kg/min, however, most patients can be maintained at a rate of 10 mcg/kg/minIndicated for cardiovascular decompensation due to ventricular dysfunction or low-output heart failureAgent of choice for management of Cardiogenic ShockLess effect on Heart Rate than Dopamine(T. 212)
77 Inotropic AgentsNorepinephrine (Levophed): start infusion at 2 mcg/min and titrate to achieve desired blood pressure.Used when there is inadequate response to other pressors.Lowest dosage that maintains BP should be used in order to minimize the complications of vasoconstrictionIncreased survival rates of up to 40% in septic shock have been reported in the literature(T. 246)
78 End Point of Resuscitation Normalization of blood pressure, heart rate, and urine outputGoal is to maximize survival and minimize morbidity using objective hemodynamic and physiologic values to guide therapy