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Robert A. Giles, MD, FACEP Emergency Department Patient Hypertensive Emergencies: What treatment modalities do emergency physicians utilize in the ED?

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Presentation on theme: "Robert A. Giles, MD, FACEP Emergency Department Patient Hypertensive Emergencies: What treatment modalities do emergency physicians utilize in the ED?"— Presentation transcript:

1 Robert A. Giles, MD, FACEP Emergency Department Patient Hypertensive Emergencies: What treatment modalities do emergency physicians utilize in the ED?

2 Robert A. Giles, MD, FACEP Atlantic City, NJ September 24, EMA Advanced Emergency & Acute Care Medicine Conference Atlantic City, NJ September 24, 2007

3 Robert A. Giles, MD, FACEP Robert A. Giles, MD, FACEP Department of Emergency Medicine Clara Maass Medical Center Belleville, NJ

4 Robert A. Giles, MD, FACEP Disclosures No disclosures No disclosures

5 Robert A. Giles, MD, FACEP Hypertensive Crisis Hypertensive urgency: Hypertensive urgency: elevation of blood pressure without acute end organ damage elevation of blood pressure without acute end organ damage Hypertensive emergency Hypertensive emergency elevation of blood pressure with acute end organ damage elevation of blood pressure with acute end organ damage Diastolic BP usually >120 in both instances Diastolic BP usually >120 in both instances

6 Robert A. Giles, MD, FACEP Sessions Objectives Identify agents for hypertensive emergencies Identify agents for hypertensive emergencies What hypertensive emergencies? What hypertensive emergencies? What are management principles? What are management principles? Which agents are best suited for the given clinical scenario? Which agents are best suited for the given clinical scenario?

7 Robert A. Giles, MD, FACEP ED Hypertensive Emergencies: Therapies Nitrates: NTG, sodium nitroprusside Beta-blockers: labetalol*, esmolol Ca channel blockers: nicardipine ACE inhibitors: enalaprilat SVR modulators: fenoldopam, hydralazine, phentolamine

8 Robert A. Giles, MD, FACEP Nitrates Nitroglycerin indications: ACS, CHF, pulmonary edema Nitroglycerin indications: ACS, CHF, pulmonary edema Dilates venous circulation and coronary artery dilator by stimulating nitric oxide release Dilates venous circulation and coronary artery dilator by stimulating nitric oxide release Cerebral vasodilatation commonly results in headache when administered Cerebral vasodilatation commonly results in headache when administered Tachyphylaxis commonly seen Tachyphylaxis commonly seen

9 Robert A. Giles, MD, FACEP Nipride Indicated first line for hypertensive emergencies Indicated first line for hypertensive emergencies Onset within seconds, duration 1-2 min. Onset within seconds, duration 1-2 min. Dose mcg/kg/min Dose mcg/kg/min Arteriolar and venous dilator with rapid onset action and short duration Arteriolar and venous dilator with rapid onset action and short duration Use limited by need for arterial BP monitoring Use limited by need for arterial BP monitoring Risk for cyanide toxicity, coronary steal Risk for cyanide toxicity, coronary steal

10 Robert A. Giles, MD, FACEP Beta Blockers Esmolol Esmolol Short acting, selective beta blocker Short acting, selective beta blocker Onset within 5 min, half life 8 min Onset within 5 min, half life 8 min Dose 80 mg bolus,150 mcg/kg/min infusion Dose 80 mg bolus,150 mcg/kg/min infusion Reduces systolic pressure and MAP Reduces systolic pressure and MAP Decreases myocardial consumption Decreases myocardial consumption Bradycardia and asthma contraindications Bradycardia and asthma contraindications

11 Robert A. Giles, MD, FACEP Beta Blockers Labetalol Labetalol Combined alpha and beta blocker Combined alpha and beta blocker Alpha blockade- beta blockade 1:3 ratio Alpha blockade- beta blockade 1:3 ratio Onset min, duration 2-6 hours Onset min, duration 2-6 hours Dose mg bolus q 10 min., Dose mg bolus q 10 min., Alternate 2mg/min infusion Alternate 2mg/min infusion Avoid in asthmatics and bradycardia Avoid in asthmatics and bradycardia Good 1 st line agent due to combined activity Good 1 st line agent due to combined activity

12 Robert A. Giles, MD, FACEP Ca Channel Blocker Nicardipine Nicardipine Smooth muscle relaxation from blockade of Ca influx Smooth muscle relaxation from blockade of Ca influx Afterload reduction, decreases SVR Afterload reduction, decreases SVR Rapid onset of action in 5-10min, duration of 1-4 hours Rapid onset of action in 5-10min, duration of 1-4 hours Dose 5mg /h increase in 2.5 mg increments to max of 15mg/h Dose 5mg /h increase in 2.5 mg increments to max of 15mg/h Safe for post bypass patients Safe for post bypass patients

13 Robert A. Giles, MD, FACEP ACE Inhibitors Enalaprilat Enalaprilat Blocks angiotensin converting enzyme Blocks angiotensin converting enzyme Useful for treating CHF and hypertensive emergencies Useful for treating CHF and hypertensive emergencies mg q 6 hr iv mg q 6 hr iv 1.25 mg IV equal to 5 mg po 1.25 mg IV equal to 5 mg po

14 Robert A. Giles, MD, FACEP Other Agents: Fenoldapam Fenoldapam Fenoldapam Dopamine agonist Dopamine agonist Reduces SVR, increases renal perfusion Reduces SVR, increases renal perfusion Short term agent, tolerance dvlps in 48 hr Short term agent, tolerance dvlps in 48 hr Onset min, duration min Onset min, duration min Dose mcg/kg/min, titrate 0.1 mcg q 15 min, max 1.6 mcg/kg/min Dose mcg/kg/min, titrate 0.1 mcg q 15 min, max 1.6 mcg/kg/min

15 Robert A. Giles, MD, FACEP Other Agents: Hydralazine Hydralazine Hydralazine Vasodilator Vasodilator Safe in pregnancy Safe in pregnancy Reflex tachycardia, lupus like syndrome Reflex tachycardia, lupus like syndrome Onset 10 min, duration hr Onset 10 min, duration hr Dose mg bolus Dose mg bolus mcg/kg/min infusion mcg/kg/min infusion

16 Robert A. Giles, MD, FACEP Other Agents: Phentolamine Phentolamine Phentolamine Alpha blocker Alpha blocker Reduces SVR Reduces SVR Dose mg Dose mg Infusion mcg/kg/min Infusion mcg/kg/min

17 Robert A. Giles, MD, FACEP ED Hypertensive Emergencies: End Organ Damage Assess for end organ damage CNS: Encephalopathy, ischemia, ICH Cardiopulmonary: ACS, AMI, edema Vascular: Aortic dissection, aneurysm Renal failure or insufficiency Gastrointestinal ischemia Pregnancy induced HTN

18 Robert A. Giles, MD, FACEP ED Hypertensive Emergencies: End Organ Damage Neurological emergencies Neurological emergencies Encephalopathy, intracerebral hemorrhage and subarachnoid hemorrhage Encephalopathy, intracerebral hemorrhage and subarachnoid hemorrhage Reduce blood pressure 25% or to diastolic 100 mm Hg Reduce blood pressure 25% or to diastolic 100 mm Hg

19 Robert A. Giles, MD, FACEP Case Presentation 64 year old presents to ED Trouble using L hand and slurred speech Symptoms for 60 minutes No headache or trauma History of TIA x 1, similar symptoms Hx DM, HTN, smoker BP 240/135

20 Robert A. Giles, MD, FACEP ED Patient Management Verify hypertensive emergency Recheck BP yourself Check manually as needed Calculate MAP Determine baseline chronic BP

21 Robert A. Giles, MD, FACEP MAP Calculation BP 240/135 MAP = 1/3 SBP + 2/3 DBP One third systolic = 80 Two thirds diastolic = 90 MAP = 170 mm Hg

22 Robert A. Giles, MD, FACEP ED Patient BP Management BP 240/135 MAP = 170 mm Hg 25% reduction?? MAP = 130 mm Hg BP 180/105

23 Robert A. Giles, MD, FACEP ED CVA Pt Blood Pressure Rx Acute CVA Acute CVA Blood pressure reduction not advised except extremely elevated diastolic >130, or in preparation for thrombolysis Blood pressure reduction not advised except extremely elevated diastolic >130, or in preparation for thrombolysis Nipride, Labetalol (NTG) Nipride, Labetalol (NTG)

24 Robert A. Giles, MD, FACEP ED Myocardial Ischemia Pt Severe hypertension with myocardial ischemia Severe hypertension with myocardial ischemia Goal: reduce SVR, improve coronary flow Goal: reduce SVR, improve coronary flow Nitroglycerin, Nipride Nitroglycerin, Nipride

25 Robert A. Giles, MD, FACEP ED Aortic Dissection Pt Aortic dissection Aortic dissection Type A blood pressure reduction plus surgery Type A blood pressure reduction plus surgery Type B medical management- reduce shearing forces Type B medical management- reduce shearing forces B blocker + nipride B blocker + nipride Labetalol Labetalol

26 Robert A. Giles, MD, FACEP ED HTN Pt with Renal Dx Renal insufficiency Renal insufficiency Precipitant and manifestation of severe hypertension Precipitant and manifestation of severe hypertension Reduce SVR without sacrificing perfusion and GFR Reduce SVR without sacrificing perfusion and GFR Fenoldopam Fenoldopam Beta & Ca channel blockers options which do not change Beta & Ca channel blockers options which do not change

27 Robert A. Giles, MD, FACEP Hypertension in Pregnancy Pre eclampsia and eclampsia Pre eclampsia and eclampsia Many traditional agents contraindicated in pregnancy Many traditional agents contraindicated in pregnancy Hydralazine Hydralazine Labetalol Labetalol

28 Robert A. Giles, MD, FACEP ED HTN Pts: Catecholamines Pheochromocytoma, cocaine abuse Pheochromocytoma, cocaine abuse Hypertensive crisis from catecholamine excess Hypertensive crisis from catecholamine excess Controlled with alpha blockade Controlled with alpha blockade Phentolamine Phentolamine Avoid Beta blockers Avoid Beta blockers

29 Robert A. Giles, MD, FACEPConclusions Many hypertensive emergencies Treatment options must be individualized for each patient Goals for BP control critical Optimal Rx limits complications, enhances patient outcomes

30 Robert A. Giles, MD, FACEP Questions? ferne_ema_2007_htn_emergencies_giles_rx_092407_finalcd 4/18/2015 5:13 PM


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