1. Case
60 F with PMH HTN, DM, CVA presented to UNC ED CC: seizure. Per the daughter the pt was walking and all of a sudden fell and her whole body started shaking. No bladder or bowel incontinence. Post-ictal in the ambulance. Vitals HR 84 BP 260/180 RR14 100% RA
- BP meds Metoprolol 150 mg daily
Amlodipine 10 mg daily

2. What is the diagnosis? A. Primary Seizure Disorder B. Stroke
C. Hypertensive Urgency
D. Hypertensive Emergency

3. Doctor? Doctor? A. Head CT B. 12 Lead EKG C. CXR D. IV Labetalol Drip
E. Place an arterial line
F. Chemistry, UA
G. Cardiac Biomarkers

4. Hypertensive Emergency
Intern Conference
September 2009

5. Urgency vs. Emergency Urgency Emergency
Any situation in which a rapid decrease in BP is required to limit end-organ damage.
Emergency
Elevated blood pressure with evidence of end organ damage

6. Causes Malignant Hypertension Aortic dissection Acute MI
Acute glomerulonephritis
Scleroderma renal crisis
Pheochromocytoma
Cocaine
Eclampsia

7. End Organ Damage Unstable angina Acute myocardial infarction
Encephalopathy
Acute Retinopathy
Nephropathy
LV failure
Dissecting aneurysm

8. Major Clinical Manifestations
Retinal hemorrhages and exudates

9. Major Clinical Manifestations
Papilledema
Papilledema is the term reserved for a swollen optic disc caused by increased intracranial pressure. Papilledema is nearly always found in both eyes, although the swelling may be asymmetric.

10. Major Clinical Manifestations
Malignant nephrosclerosis, leading to acute renal failure, hematuria, and proteinuria

11. Major Clinical Manifestations
Neurologic symptoms due to intracerebral or subarachnoid bleeding, lacunar infarcts, or hypertensive encephalopathy
PRES (reversible posterior leukoencephalopathy
Acutely hypertensive month later normotensive

12. Management of hypertensive encephalopathy
The initial aim of treatment in hypertensive emergency is to rapidly lower the diastolic pressure to about 100 to 105 mmHg; this goal should be achieved within two to six hours, with the maximum initial fall in BP not exceeding 25 percent of the presenting value

13. Drugs
Nitroprusside — an arteriolar and venous dilator, given as an intravenous infusion. Initial dose: 0.25 to 0.5 µg/kg per min; maximum dose: 8 to 10 µg/kg per min. Nitroprusside acts within seconds and has a duration of action of only two to five minutes.
Concern for what???
Cyanide toxicity with prolonged use and renal failure
Nicardipine — an arteriolar dilator, given as an intravenous infusion. Initial dose: 5 mg/h; maximum dose: 15 mg/h.
Labetalol — an alpha- and beta-adrenergic blocker, given as an intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min.
Fenoldopam — a peripheral dopamine-1 receptor agonist, given as an intravenous infusion. Initial dose: 0.1 µg/kg per min; the dose is titrated at 15 min intervals, depending upon the blood pressure response

14. Oral Therapy
Once BP is controlled transition the patient to oral therapy
Start orals while drip is still going and allow nurse to wean the drip based on the MAP
Be careful not to overshoot and cause hypotension

15. Prognosis
Even with adequate antihypertensive therapy most patients still have moderate to severe vascular damage occurring
At higher risk for coronary, cerebrovascular and renal disease

16. Case Head CT to evaluate for edema MRI to evaluate for stroke
Every hypertensive emergency deserves an examination of renal artery stenosis via dopplers or MRA

17. Take Home Points
In hypertensive emergency, control the diastolic blood pressure within the first two to six hours with IV drip and with an arterial line in stepdown or ICU
Perform a fundoscopic exam upon admission
Transition to oral therapy once goal is achieved
Diastolic BP should be reduced to over two to three months.