DOCSLIB.ORG

Hypertensive Crises: Diagnosis and Management in the Emergency Room

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Hypertensive Crises: Diagnosis and Management in the Emergency Room European Review for Medical and Pharmacological Sciences 2004; 8: 143-152 Hypertensive crises: diagnosis and management in the emergency room A. MIGNECO, V. OJETTI, A. DE LORENZO**, N. GENTILONI SILVERI, L. SAVI* Dept. of Emergency Medicine, Catholic University - Rome (Italy) *Dept. of Internal Medicine, Catholic University - Rome (Italy) **Human Nutrition Unit, University of Tor Vergata - Rome (Italy) Abstract. – Hypertensive crises are com- by the absolute BP levels, but also by the monly observed in an emergency room. magnitude and the rate of the pressure in- Regardless blood pressure values, hyperten- crease and by the underlying conditions3,4. sive crises are classified in emergencies, char- acterized by life-threatening acute organ dam- For instance, blood pressure levels in eclamp- age, and urgencies, with no evidence of acute sia may be only slightly elevated; neverthe- or progressive organ injury. In an hypertensive less, immediate treatment of hypertension in emergency an appropriate and immediate man- this setting is mandatory. agement with parenteral drugs is mandatory, Hypertensive crises are traditionally subdi- while in an hypertensive urgency blood pres- vided in hypertensive emergencies and ur- sure should be decreased within 24-48 h with 5-7 orally active agents. gencies . This article reviews the spectrum of clinical The presence of acute or progressive life syndromes that comprise hypertensive emer- threatening organ damage such as acute coro- gencies, focusing on specific drugs and thera- nary syndrome, acute left ventricular failure peutic strategies available in the emergency with pulmonary oedema, eclampsia, aortic department, based on current literature. dissection, acute renal failure, hypertensive Since no randomized prospective trials are encephalopathy and haemorragic/ischaemic available, an evidence-based approach recom- mending an optimal therapeutical management stroke constitutes an hypertensive emer- 5-7 is not possible. Much of the therapy is there- gency . Many authors consider also accelerat- fore entirely empirical and based on the under- ed-malignant hypertension an emergency, be- lying pathophysiologic and clinical findings. cause sudden occurrence of complications such Further studies are needed to clarify patho- as stroke, acute renal failure or acute coronary physiologic mechanisms in order to optimize syndrome in this setting is possible8-10. therapeutic approach. In most hypertensive emergencies, BP Key Words: should be lowered within minutes using Hypertension, Hypertensive emergency, Hypertensive parental drugs1,5,6. urgency, Hypertensive crises, Hypertensive complication, An hypertensive urgency is an hyperten- Treatment. sive crises without acute or progressive organ damage, and BP should be lowered in 24-48 hours to prevent development of acute organ damage1,5,7. According to the JNC VII, hyper- tensive urgencies include upper levels of Introduction stage II hypertension with symptoms like headache, dizziness, severe anxiety, epistaxis Definition and shortness of breath. Some authors in- Hypertensive crisis is defined as a critical clude in the definition also hypertensive elevation of blood pressure in which diastolic crises in patients without evidence of acute or blood pressure (BP) generally exceeds 120 progressive organ damage but at high risk for mmHg1,2. This threshold value is, however, developing new injury (patients with known not univocally established, since the severity target organ diseases such as chronic is- of the clinical picture is not only determined chaemic heart disease or previous stroke)11. 143 A. Migneco, V. Ojetti, A. De Lorenzo, N. Gentiloni Silveri, L. Savi Casual detection of asymptomatic high BP initiated. Proinflammatory and adhesion mol- levels without any sign of acute or progres- ecules are released from the impaired en- sive organ involvement may be defined as dothelial cell layer, promoting local perme- simple blood pressure rise11. Simple blood ability, inflammation and vasoconstriction15. pressure rise may further be classified as The clinical picture of an hypertensive transient hypertension (generally a cardiovas- crises may range from an asymptomatic pre- cular response to pain or anxiety) or stable sentation to specific symptoms characterizing uncomplicated hypertension12. an acute organ damage (dyspnea, chest pain, neurological disorders). In the absence of or- Ethiology, Pathogenesis, Clinical Picture gan manifestations the patient may complain and Diagnosis about non-specific symptoms such as palpita- Any disorder that causes hypertension can tions, headache, dizziness. give rise to a hypertensive emergency (Table By documenting the medical history, the I). The rate of change in blood pressure de- medical status and by simple diagnostic proce- termines the likelihood that an acute hyper- dures (ECG, fundoscopy, laboratory exams, tensive syndrome will develop4. Pre-existing and when indicated, chest ray, cerebral or chest hypertension may lower the probability of an CT scan) the differential diagnosis between hypertensive emergency through adaptive emergency and urgency can generally be estab- vascular changes that protect end organs lished at the emergency site within a very short from acute changes in BP13. period of time. This approach may also give The pathophysiology of the hypertensive some clues to define the cause of the hyperten- crises is complex and incompletely under- sive crises (e.g., cocaine abuse, pheochromocy- stood: an initial abrupt rise in vascular resis- toma, poorly controlled or previously un- tance seems to be a necessary first step. This known stage II hypertension), guiding to a increased vasoreactivity may be precipitated more appropriate therapy. When an hyperten- by the release of vasodynamic substances such sive emergency is suspected, treatment should as norepinephrine and angiotensin II and can be started as soon as possible, even before the occur as a result of relative hypovolemia13,14. results of these exams are available. The compensatory endothelial vasodilatory responses are overwhelmed, leading to en- dothelial decompensation, which promotes further rises in BP13. Thus, a vicious circle, Management of with progressive increases on vascular resis- Hypertensive Emergencies tance and further endothelial dysfunction is Several parenteral agents are available for the treatment of hypertensive emergencies Table I. Causes of hypertensive emergencies. (Table II). Intravenous agents are generally preferred in this setting, since the effect of • Essential hypertension: poorly controlled blood the treatment is rapid and occurs within a cal- pressure, antihypertensive drugs withdrawal culable period of time13. Moreover, intra- • Renal parenchymal diseases: acute glomeru- venous treatment can be better regulated lonephritis, vasculitis, haemolytic uraemic syn- drome, thrombotic thrombocytopenic purpura than medication administered orally or by the • Renovascular diseases sublingual route . • Endocrine diseases: pheocromocytoma, Cushing’s Before administering the treatment, the syndrome, renin secreting tumors, mineralcorti- risk of worsening of the end-organ damage coid hypertension (rare) must be weighed against the risk of rapid • Drugs: cocaine, sympathomimetics, erythropoi- blood pressure lowering. Gradually decrease etin, cyclosporine, interactions with monoamine- of mean BP level while minimizing the risk of oxidase inhibitors (tyramine), amphetamines hypoperfusion is the most important thera- • Autonomic hyperactivity: Guillame-Barrè syn- peutic principle in this setting16. For instance, drome, acute intermittent porphyria patients with chronic hypertension have an • Central nervous system disorders: head injury, altered cerebral autoregulation curve17, and cerebral infarction/haemorrhage, brain tumors • Eclampsia acute normotension would lead to cerebral hypoperfusion. 144 Hypertensive crises: diagnosis and management in the emergency room Table II. Parenteral drugs for treatment of hypertensive emergencies: pharmacological properties. Drug Dose Onset of Duration Mechanism action of action of action Labetalol 20-80 mg iv boluses or 10 min 3-6 h α/β-adrenergic 0.5-2 mg/min by infusion blocker Esmolol 250-500 mg/kg/min 1-2 min 10-30 min β-adrenergic blocker iv bolus, then 50-100 µg /kg/min by infusion Phentolamine 5-15 mg iv boluses 1-2 min 10-30 min α-adrenergic antagonist Urapidil 25 mg iv boluses or 3-5 min 4-6 h α-adrenergic 5-40 mg/h by infusion antagonist Fenoldopam 0.1-0.3 mg/kg/min 5 min 30 min Dopamine 1 by infusion receptor agonist Nicardipine 5-15 mg/h by infusion 5-10 min 15-30 min Calcium-channel blocker Enalaprilat 1.25-5 mg boluses 15-30 min 6-12 h ACE inhibitor every 6h Sodium 0.25-10 mg/kg/min Immediate 1-2 min Nitric oxid Nitroprussiate by infusion compound direct venous and arterial vasodilator Nitroglicerine 5-100 mg/min 2-5 min 5–10 min Nitric oxid by infusion compound direct venous and arterial vasodilator (mainly venous) Hydralazine 10-20 mg iv 10–20 min 1-4 h Direct vasodilator boluses To avoid cerebral, coronary and renal is- the reliable effectiveness and on the con- chemia, mean BP levels should be reduced traindications of the drugs (Table 3). Other approximately by 25% within few minutes, selection criteria are duration of pressure reaching the goal of 160/100 mmHg within 2- elevation and underlying conditions (e.g., 6 hours5,18. BP should then be normalized in prior cardiovascular, cerebrovascular or re- the following 24-48 h. Patients with aortic dis- nal disorders).
Load more

Recommended publications
  • Hypertensive Emergency: an Overview of Heart As Target Organ Damage
    ORIGINAL ARTICLE Bali Medical Journal (Bali Med J) 2020, Volume 9, Number 3: 903-906 P-ISSN.2089-1180, E-ISSN: 2302-2914 Hypertensive emergency: an overview of heart as target organ damage Starry Homenta Rampengan1*, H J Sunarto2 ABSTRACT Hypertension is currently still a global problem in the cardiology cells’ death affected heart structure and its function. The symptoms and vascular fields with an increasing trend. One of the emergency that appear can be in the form of acute coronary syndrome or acute conditions related to an increase in blood pressure is emergency heart failure. Some modalities can detect heart structure changes, hypertension. Emergency hypertension is a condition where blood like electrocardiography for general and echocardiography for pressure rises rapidly and severely, resulting in new or progressive specific examination. Hypertensive emergencies can be treated organ damage. Symptoms can range from chest pain, shortness by several rapid-acting antihypertensive agents, which can be of breath to delirium. The heart is one of the organs that can be selected based on the clinical manifestations. As the symptoms damaged by hypertensive emergencies. The availability and related to heart damage are acute coronary syndrome and acute demand for oxygen from the coronary blood vessels to the heart heart failure, so the treatment will be specific, respectively. Good muscle cells will experience an imbalance due to a sudden increase knowledge related to emergency hypertension management and in blood pressure. Lack of oxygen that occurs can cause heart muscle early treatment will reduce patient morbidity. Keywords: hypertensive emergency, heart, organ damage Cite this Article: Rampengan, S.H., Sunarto, H.J.
    [Show full text]
  • Aortic Thrombus Causing a Hypertensive Emergency
    CASE REPORT Aortic Thrombus Causing a Hypertensive Emergency Kraftin E. Schreyer, MD*† *Temple University Hospital, Department of Emergency Medicine, Philadelphia, Jenna Otter, MD* Pennsylvania Zachary Johnston, BS† †Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania Section Editor: Rick A. McPheeters, DO Submission history: Submitted February 9, 2017; Revision received June 27, 2017; Accepted June 28, 2017 Electronically published November 3, 2017 Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.2017.6.33876 Thoracic aorta thrombi are a rare condition typically presenting as a source for distal embolization in elderly patients with atherosclerotic risk factors. However, young patients with a variety of presentations resulting from such thrombi have rarely been reported. We describe a case of a young patient with refractory hypertensive emergency caused by a large thoracic aorta thrombus. Investigation was guided by abnormal physical exam findings. [Clin Pract Cases Emerg Med.2017;1(4):387–390.] INTRODUCTION supine positioning. It had progressively worsened over the Thoracic aorta thrombi are exceedingly rare. When they course of one day and was associated with chest pain, do occur, they typically present as a source of distal subjective fever, and cough productive of blood-tinged embolization, clinically resulting in stroke, transient sputum. According to the patient, he had experienced similar ischemic attack, or arterial embolization of an extremity. symptoms when he was diagnosed with PJP pneumonia. Diagnosis of thoracic aorta thrombi is often made in older On initial exam, the patient had a blood pressure (BP) of patients with atherosclerotic risk factors or known 247/128 mmHg, pulse of 135 beats per minute, and an aneurysmal or atherosclerotic disease.1,2 Thrombi have also oxygen saturation of 86% on room air.
    [Show full text]
  • Life-Threatening Events in Patients with Pheochromocytoma
    A Riester and others Life-threatening events in 173:6 757–764 Clinical Study pheochromocytoma Life-threatening events in patients with pheochromocytoma Anna Riester, Dirk Weismann1, Marcus Quinkler2, Urs D Lichtenauer3, Sandra Sommerey4, Roland Halbritter5, Randolph Penning6, Christine Spitzweg7, Jochen Schopohl, Felix Beuschlein and Martin Reincke Medizinische Klinik und Poliklinik IV, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians-Universita¨ t, Ziemssenstr. 1, D-80336 Munich, Germany, 1Medizinische Klinik und Poliklinik I, Universita¨ tsklinikum Wu¨ rzburg, Correspondence Wu¨ rzburg, Germany, 2Endokrinologie in Charlottenburg, Berlin, Germany, 3Helios Klinik Schwerin, Schwerin, should be addressed Germany, 4Chirurgische Klinik und Poliklinik – Innenstadt, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians- to M Reincke Universita¨ tMu¨ nchen, Munich, Germany, 5Facharztpraxis, Pfaffenhofen, Germany, 6Institut fu¨ r Rechtsmedizin and Email 7Medizinische Klinik und Poliklinik II, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians-Universita¨ t, Munich, martin.reincke@ Germany med.uni-muenchen.de Abstract Objective: Pheochromocytomas are rare chromaffin cell-derived tumors causing paroxysmal episodes of headache, palpitation, sweating and hypertension. Life-threatening complications have been described in case reports and small series. Systematic analyses are not available. We took an opportunity of a large series to make a survey. Design and methods: We analyzed records of patients diagnosed with pheochromocytomas in three geographically spread German referral centers between 2003 and 2012 (nZ135). Results: Eleven percent of the patients (ten women, five men) required in-hospital treatment on intensive care units (ICUs) due to complications caused by unsuspected pheochromocytomas. The main reasons for ICU admission were acute catecholamine induced Tako-Tsubo cardiomyopathy (nZ4), myocardial infarction (nZ2), acute pulmonary edema (nZ2), cerebrovascular stroke (nZ2), ischemic ileus (nZ1), acute renal failure (nZ2), and multi organ failure (nZ1).
    [Show full text]
  • Hypertensive Emergency
    Presentation of hypertensive emergency Definitions surrounding hypertensive emergency Hypertension: elevated blood pressure (BP), usually defined as BP >140/90; pathological both in isolation and in association with other cardiovascular risk factors Severe hypertension: systolic BP (SBP) >200 mmHg and/or diastolic BP (DBP) >120 mmHg Hypertensive urgency: severe hypertension with no evidence of acute end organ damage Hypertensive emergency: severe hypertension with evidence of acute end organ damage Malignant/accelerated hypertension: a hypertensive emergency involving retinal vascular damage Causes of hypertensive emergency Usually inadequate treatment and/or poor compliance in known hypertension, the causes of which include: Essential hypertension o Age o Family history o Salt o Alcohol o Caffeine o Smoking o Obesity Secondary hypertension o Renal . Renal artery stenosis . Glomerulonephritis . Chonic pyelonephritis . Polycystic kidney disease o Endocrine . Cushing’s syndrome . Conn’s syndrome . Acromegaly . Hyperthyroidism . Phaeochromocytoma o Arterial . Coarctation of the aorta o Drugs . Alcohol . Cocaine . Amphetamines o Pregnancy . Pre-eclamplsia Pathophysiology of hypertensive emergency Abrupt rise in systemic vascular resistance Failure of normal autoregulatory mechanisms Fibrinoid necrosis of arterioles Damage to red blood cells from fibrin deposits causing microangiopathic haemolytic anaemia Microscopic haemorrhage Macroscopic haemorrhage Clinical features of hypertensive emergency Hypertensive encephalopathy o
    [Show full text]
  • Therapy Management Guide
    INLYTA® (axitinib) + pembrolizumab THERAPY MANAGEMENT GUIDE Dosing recommendations and management strategies when INLYTA is used in combination with pembrolizumab for the first-line treatment of advanced RCC When INLYTA is used in combination with pembrolizumab, please refer to the full Prescribing Information for pembrolizumab for full dosing and AR management information INDICATION INLYTA in combination with pembrolizumab is indicated for the first-line treatment of patients with advanced renal cell carcinoma (RCC). IMPORTANT SAFETY INFORMATION Hypertension including hypertensive crisis has been observed. Blood pressure should be well controlled prior to initiating LIN YTA. Monitor for hypertension and treat as needed. For persistent hypertension despite use of antihypertensive medications, reduce the dose. Discontinue INLYTA if hypertension is severe and persistent despite use of antihypertensive therapy and dose reduction of INLYTA, and discontinuation should be considered if there is evidence of hypertensive crisis. Arterial and venous thrombotic events have been observed and can be fatal. Use with caution in patients who are at increased risk for, or who have a history of, these events. Hemorrhagic events, including fatal events, have been reported. INLYTA has not been studied in patients with evidence of untreated brain metastasis or recent active gastrointestinal bleeding and should not be used in those patients. If any bleeding requires medical intervention, temporarily interrupt the INLYTA dose. Please see additional Important
    [Show full text]
  • Journal of Advances in Internal Medicine Vol01 Issue01
    Vikram Singh Tanwar, et al. Takayasu Arteritis presenting with hypertensive encephalopathy| Case Report Takayasu arteritis presenting as renovascular hypertension with hypertensive encephalopathy Vikram Singh Tanwar,1* Anjali Saini,2 Anurag Ambroz Singh,1 Rakesh Tank,1 1Department of medicine, SHKM GMC Nalhar (122107) India, 2PGIMS Rohtak (124001) India DOI Name http://dx.doi.org/10.3126/jaim.v6i2.18540 Keywords Takayasu arteritis, vasculitis, hypertensive encephalopathy Citation Vikram Singh Tanwar, Anjali Saini, Anurag Ambroz Singh, Rakesh Tank. Takayasu arteritis presenting as renovascular hypertension with hypertensive encephalopathy. Journal of Advances in Internal ABSTRACT Medicine 2017;06(02):35-37. Takayasu arteritis is a large vessel vasculitis that has variable presentation. It is suspected when there are pulse and BP discrepancies between upper limbs or absent pulses. We here presenting a case of takayasu arteritis that remained This work is licensed under a Creative Commons undiagnosed till 40 years and at first time manifested with hypertensive Attribution 3.0 Unported License. encephalopathy and managed well with medical therapy. INTRODUCTION i.e. 210/130 mmHg (measured in right arm taken in supine Takayasu Arteritis (TA) is a type of chronic granulomatous position) but in left arm BP was not recordable. Pulse (radial vasculitis of unknown cause (majority of authors agree on its and brachial) was not palpable in left upper limb. Pulse was autoimmue etiology). It has worldwide distribution, with the well palpable in right upper limbs and both lower limbs. No greatest prevalence among Asians. TA commonly manifest other abnormal clinical finding was detected on cardiovascular, with various constitutional symptoms like fever, bodyache, respiratory and neurological examination.
    [Show full text]
  • Hypertensive Emergencies Are Associated with Elevated Markers of Inflammation, Coagulation, Platelet Activation and fibrinolysis
    Journal of Human Hypertension (2013) 27, 368–373 & 2013 Macmillan Publishers Limited All rights reserved 0950-9240/13 www.nature.com/jhh ORIGINAL ARTICLE Hypertensive emergencies are associated with elevated markers of inflammation, coagulation, platelet activation and fibrinolysis U Derhaschnig1,2, C Testori2, E Riedmueller2, S Aschauer1, M Wolzt1 and B Jilma1 Data from in vitro and animal experiments suggest that progressive endothelial damage with subsequent activation of coagulation and inflammation have a key role in hypertensive crisis. However, clinical investigations are scarce. We hypothesized that hypertensive emergencies are associated with enhanced inflammation, endothelial- and coagulation activation. Thus, we enrolled 60 patients admitted to an emergency department in a prospective, cross-sectional study. We compared markers of coagulation, fibrinolysis (prothrombin fragment F1 þ 2, plasmin–antiplasmin complexes, plasmin-activator inhibitor, tissue plasminogen activator), platelet- and endothelial activation and inflammation (P-selectin, C-reactive protein, leukocyte counts, fibrinogen, soluble vascular adhesion molecule-1, intercellular adhesion molecule-1, myeloperoxidase and asymmetric dimethylarginine) between hypertensive emergencies, urgencies and normotensive patients. In hypertensive emergencies, markers of inflammation and endothelial activation were significantly higher as compared with urgencies and controls (Po0.05). Likewise, plasmin–antiplasmin complexes were 75% higher in emergencies as compared with urgencies (Po0.001), as were tissue plasminogen-activator levels (B30%; Po0.05) and sP-selectin (B40%; Po0.05). In contrast, similar levels of all parameters were found between urgencies and controls. We consistently observed elevated markers of thrombogenesis, fibrinolysis and inflammation in hypertensive emergencies as compared with urgencies. Further studies will be needed to clarify if these alterations are cause or consequence of target organ damage.
    [Show full text]
  • Hypertensive Urgency (Asymptomatic Severe Hypertension): Considerations for Management
    www.RxFiles.ca ‐ updated June 2016 RxFiles Q&A Summary K Krahn , L Regier UofS BSP Student 2014 BSP, BA HYPERTENSIVE URGENCY (ASYMPTOMATIC SEVERE HYPERTENSION): CONSIDERATIONS FOR MANAGEMENT Hypertension is one of the most common chronic medical conditions in Canada. More than one in five Canadians has hypertension and the lifetime risk of developing hypertension is 90%.1 With the addition of comorbid conditions and other risk factors, hypertensive cases can quickly become even more complex. Hypertensive crises include hypertensive urgencies & emergencies. Optimal management lacks conclusive evidence. The rate of associated major adverse cardiovascular events in asymptomatic patients seen in the office are very low.13 Since rapid treatment of hypertensive urgency is not required, some prefer to call it asymptomatic severe hypertension. 1,2,3 ,4,5,6,7,8,9 WHAT IS HYPERTENSIVE URGENCY & HOW DOES IT COMPARE TO HYPERTENSIVE EMERGENCY? The term hypertensive crises can be further divided into hypertensive urgency and hypertensive emergency. The distinction between these two conditions is outlined below.8 Differentiating between these scenarios is essential before initiating treatment. URGENCY 2‐9 EMERGENCY 2‐9 Blood Pressure (mmHg) >180 systolic &/or >120 ‐ >130 CHEP diastolic No Yes: currently experiencing (e.g. aortic dissection, angina/ACS, stroke, Target Organ Damage* encephalopathy, acute renal failure, pulmonary edema, eclampsia) Asymptomatic; or severe headache, shortness Shortness of breath, chest pain, numbness/weakness, change in Symptoms of breath, nosebleeds, severe anxiety vision, back pain, difficulty speaking *Note: Signs of end‐organ damage/dysfunction may occur at a lower blood pressure in pregnant & pediatric patients Initial Patient Work‐Up to Differentiate between Urgency and Emergency: Verify blood pressure (BP) reading(s).
    [Show full text]
  • Hypertensive Emergency)
    Hypertensive Crisis Adj Asst Prof Ashish Anil Sule, Senior Consultant, GM, Vascular Medicine and hypertension MD, MRCP, FRCP, FAMS, ESH specialist Overview • Case • Definition - Urgency/ Emergency and others • Evaluation, diagnosis and approach – 1. How quickly to reduce blood pressure 2. Is there any BP target 3. How should this goal be achieved • Treatment with intravenous anti-hypertensive and conditions Question 1 30 years old gentleman, presented to emergency for hypertensive urgency with severe chest pain. He was diagnosed to have aortic dissection. Which is the first line of treatment for this patient ? • Intravenous Nitroglycerine • Intravenous Labetelol • Intravenous Nitroprusside • Intravenous Phentolamine • Oral Captopril Question 2 What should be his target blood pressure and within how much time this should be achieved: • Lower BP to 100-120 mm Hg within 20 minutes • Lower BP to 120-140 mm Hg within 40 minutes • Lower BP to 140-160 mm Hg within 20 minutes • Lower BP to 140-160 mm Hg within 40 minutes Question 3 45 years old gentleman, known case of hypertension presented with sudden loss of consciousness. O/E- BP 200/120 mm Hg, patient was drowsy. CT brain showed evidence of cerebellar bleed. Which is the ideal choice of anti-hypertensive ? • IV nitroprusside • IV Nitroglycerine • IV Nicardipine • IV Phentolamine • Oral captopril Question 4 In the same patient : what target of systolic BP should be achieved • <140 mm Hg • <160 mm Hg • <180 mm Hg • <200 mm Hg • None of the above GRR Past Medical History 71 years female 1. Resistant Hypertension secondary Indian, to right renal stenosis ADL independent - s/p Right artery stenting 22/3/16 community ambulant 2.
    [Show full text]
  • Epistaxis Treatment Using Injectable Form Recommended for Pts with Recurrent Bleeds, Bilateral Packing, Or Other Concerns
    EM Basic – Epistaxis Pearl: Have the patient bend forward at waist to avoid swallowing blood. (This document doesn’t reflect the views or opinions of the Department of Defense, the US Army, or the Exam: Assess VS, mental status, and airway as above. Perform a general physical SAUSHEC EM residency, ©2014 EM Basic, Steve Carroll DO. May freely distribute with proper exam as appropriate. The focused exam of the nose requires the patient to blow attribution) out clots. Pretreatment of the nares with lidocaine soaked plegits will aid the nasal Epidemiology: Bimodal age exam. Use of a nasal speculum is recommended. Attempt to find the bleeding distribution. Most cases in the 2-10 vessel(s). Inspect Kiesselbach’s plexus for bleeding, ulceration, or erosion. Assess or 50-70 year-old age groups. More the oropharynx for sanguineous drainage. Brisk bleeding that does not stop with common in winter, possibly due to direct pressure and cannot be visualized may be from a posterior source. dry climate, frequency of URI’s. Work-up: Labs are not routinely required, but anticoagulation studies should be Allergic rhinitis and use of nasal obtained for patients on anticoagulants or with known coagulopathy. Severe bleeds medications are risk factors. or signs of anemia or hemodynamic instability require a hematocrit and possibly Etiology: Majority result from digital type & screen/crossmatch and large bore IV placement, depending on severity. trauma (nose-picking). Other types of trauma or recent surgery may be Treatment responsible. Intranasal cocaine use Anterior bleeds may also provoke bleeding. If bleeding has stopped with pressure, observe for 30 minutes.
    [Show full text]
  • Hypertensive Emergencies: an Update Paul E
    Hypertensive emergencies: an update Paul E. Marika and Racquel Riverab aDepartment of Medicine, Eastern Virginia Medical Purpose of review School and bDepartment of Pharmacy, Sentara Norfolk General Hospital, Norfolk, Virginia, USA Systemic hypertension (HTN) is a common medical condition affecting over 1 billion people worldwide. One to two percent of patients with HTN develop acute elevations of Correspondence to Paul E. Marik, MD, FCCP, FCCM, Eastern Virginia Medical School, 825 Fairfax Avenue, blood pressure (hypertensive crises) that require medical treatment. However, only Suite 410, Norfolk, VA 23507, USA patients with true hypertensive emergencies require the immediate and controlled E-mail: [email protected] reduction of blood pressure with an intravenous antihypertensive agent. Current Opinion in Critical Care 2011, Recent findings 17:569–580 Although the mortality from hypertensive emergencies has decreased, the prevalence and demographics of this disorder have not changed over the last 4 decades. Clinical experience and reported data suggest that patients with hypertensive urgencies are frequently inappropriately treated with intravenous antihypertensive agents, whereas patients with true hypertensive emergencies are overtreated with significant complications. Summary Despite published guidelines, most patients with hypertensive crises are poorly managed with potentially severe outcomes. Keywords aortic dissection, clevidipine, eclampsia, esmolol, hypertension, hypertensive emergencies, labetalol, nicardipine, pulmonary edema Curr Opin Crit Care 17:569–580 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 1070-5295 of hypertension (compared to the previous four stages in Introduction JNC VI). In addition, a new category called prehyper- Systemic hypertension (HTN) is a common medical tension was added. Hypertension is defined as a SBP condition affecting over 1 billion people worldwide greater than 140 mmHg or a DBP greater than 90 mmHg and more than 65 million Americans [1,2].
    [Show full text]
  • Hypertensive Crisis in Modern Guidelines: How to Avoid Mistakes in Diagnosis and Treatment
    Архивъ внутренней медицины • № 6 • 2019 ЛЕКЦИИ DOI: 10.20514/2226-6704-2019-9-6-407-412 UDC: 616.12-008.331.1-07-08 Yu. V. Evsyutina Federal State Budgetary Institution National Medical Research Center for Preventive Medicine of the Ministry of Health of Russia, Moscow, Russia HYPERTENSIVE CRISIS IN MODERN GUIDELINES: HOW TO AVOID MISTAKES IN DIAGNOSIS AND TREATMENT. BASED ON THE MATERIALS OF THE RUSSIAN NATIONAL «HUMAN AND MEDICINE» CONGRESS AND THE III CARDIOLOGY SUMMIT Abstract The prevalence of hypertension is about 40 % according to Russian and world statistics. Approximately 1–2 % of patients with hypertension have high blood pressure throughout their lives, which requires urgent or emergency care. Hypertensive crisis is an acute condition caused by a sudden increase in blood pressure to individually high values, accompanied by clinical symptoms and requiring a controlled reduction to prevent target organ damage. According to the severity of clinical symptoms, hypertensive crisis is divided into uncomplicated and complicated. Typical signs of hypertensive crisis include malignant hypertension, severe hypertension associated with other clinical conditions, a sudden increase in blood pressure due to pheochromocytoma associated with organ damage, severe hypertension during pregnancy or preeclampsia. Hypertensive crisis is associated with various acute conditions, most often stroke (ischemic and hemorrhagic), acute cardiogenic pulmonary edema, acute heart failure, acute coronary syndrome, acute kidney injury, acute aortic dissection and eclampsia. The main goals of the treatment of hypertensive crisis are relief of the crisis, post-crisis stabilization, and prevention of repeated hypertensive crises. In patients with an uncomplicated hypertensive crisis, a decrease in mean blood pressure by 10 % during the first hour and by another 15 % during the next 2–3 hours is recommended.
    [Show full text]