19/06/2018 Hypertension • Definitions: • WHO 140/90 • Westmead: calling criteria Hypertension and • If untreated 50% die of cardiovascular disease • 33% get a stroke Hypotension • 10% will develop renal failure Dr Giles Miller Hypertension • Causes • Essential • Renal • Endocrine • Neurogenic • Psychogenic • Miscellaneous 1 19/06/2018 Hypertension Hypertension treatments • Patterns • GTN patch • Hyperdynamic • Hydralazine • Vasoconstricted • B‐blockers • End Organ Damage • Ca channel • Cardiac • Diuretics • Eyes • ACEI • Renal • Angiotensin II blockers • Cerebral • Central acting alpha agonists Case Studies ‐ 1 Case 1 Needs to be reviewed but not a high priority • 78 yr old male • Past History • Admitted with UTI and delirium. Normally lives at home with • Mild dementia daughter as carer. • Hypertension ‐ Normally well controlled with BP 130/80 • Chronic renal failure (Cr 180) Always check the Medications! • Nurse calls you BP 168/92 at 10am on sat morning. • Medications • Diuretics, ACEI. • What are you going to do? • Missed daily dose of antiHT. 2 19/06/2018 Case Studies ‐ 2 Case 2 • Usual BP 150/90. • 56yr old lady with ESRF • On multiple antiHT • Dialysis 3 times a week via left AVF • ‐metoprolol, felodipine. • Had been drinking more recently due to some hot weather. Went • Nurse calls as BP prior to dialysis is 210/100 over usual fluid restriction. Weight up by 5kg You would always check with the renal physician/med reg first • What are you going to do? • Prazocin would be a typical drug to use in this circumstance Case Studies ‐ 3 Case 3 • Pre‐eclampsia definition: SBP >140, DBP >90 with renal involvement • Pregnant lady, 34 weeks. causing proteinuria. (2+ on dipstick) • Current management is control of BP with labetalol 200mg oral (or 10mg • No previous history of hypertension IV) (avoid ACEI leads to still birth, neonatal renal failure) • Presents with headache and BP 138/100. • Can also use hydralazine • Mg prophylaxis will reduce the incidence of eclampsia only. • What are you going to do? • Try to control BP to allow foetal maturation. • Really the only solution is to take out the placenta. 3 19/06/2018 Case Studies ‐ 4 You are called to orthopaedic ward to see patient 34yr old male post MVA and fixation of leg fractures. BP 165/90. What are you going to do? Case 4 Case Studies • Clearly Pain management needs to be checked and optimised • 65 yr old male, • But don’t overlook other possibilities • Post op for cystoscopy and resection bladder tumour. • In this population the possibility of withdrawal from alcohol or other drugs is also worth considering Nurse calls for BP 158/95 4 19/06/2018 Case 5 Hypotension • Not only need to manage the Blood Pressure but any underlying • Definition causes • WHO <100/60 • In this case acute urinary retention • ARC SBP <90 • Westmead Calling criteria • Essential hypotension a normal variant Case Studies ‐ 1 Case 1 • 28 yr old male. • Admitted after trauma (MBA) with right arm fractured humerus, right rib • Bleeding is of course a concern, and a VBG will help, but young health fractures and right leg tib/fib fracture. male has to lose quite a lot of blood to start dropping BP • Sent up from ED with negative FAST and no other imaging suggestive of • The combination of decreasing sats, rib fracture an hypotentsion bleeding should also alert you to tension pneumothorax • Asked to see patient on ward prior to theatre as pt becoming short of breath (sats 96% on 2LNP) and then hypotensive (BP 95/70) • What would you do? 5 19/06/2018 Case Studies ‐ 2 • 85 yr old female admitted with small bowel obstruction for conservative management. • Nurse calls you because they have noticed the patient becoming a bit confused and dropping blood pressure Case 2 • She’s been vomiting and likely to be hypovolemic • The confusion might alert you to something else going on and sepsis is worth considering. • Immediate management is going to be fluid resus and call for help 6 19/06/2018 Case Studies ‐ 3 Case 3 • 68 yr old male with vascular disease has recently undergone • Should have high index of suspicion for Retroperitoneal bleed angiogram of right leg to assess vascular patency. They performed angioplasty with stent insertion. • You have been asked to see patient because of lower back pain and hypotention • Pt is lying flat in bed as per post op instructions. Case Studies ‐ 4 Case 4 • 54 yr old female, diabetic patient admitted for hernia repair. • In a post op patient all the usual considerations apply; dehydration, bleeding, sepsis, cardiac • Post operatively patient begins to feel dizzy and is hypotensive ‐ for • Always check op‐report aesthetic chart and medications which you have been asked to see her. • This procedure is not typically associate with high risk of bleeding, but silent MI is a risk in 50yr old diabetics –so an ECG is necessary 7 19/06/2018 Case Studies ‐ 5 • 42 yr old male post op after right leg amputation. • Intraop received 6 units blood, 4 FFP. • Started on platelets as patient arrived on ward. • Initial BP was 140/75. • Now, BP 95/60, nurse calls you. Case 5 Case Studies ‐ 6 This patient needed a lot of blood! Things worth considering • You have been asked to see patient with increased urine output post • Was his volume adequately replaced? craniotomy e/o tumour. • Coagulopathy • Pt feeling well, drowsy. • Reaction to blood products? • Hypotensive 8 19/06/2018 Case 6 • Diabetes insipidus post pituitary tumour resection, lack of ADH, loss of water permeability in collecting ducts and distal convoluted tubule (aquaporins). • Plasma osmolality increases (lack of water resorption), hypernatremia with dehydration, dilute urine with low specific gravity, urine osmolality and electrolytes are low. • Fluid deprivation test: pt should conserve, but in DI will continue to produce large volumes of urine. • Desmopressin 0.25‐1mcg if central will reduce urine output and increase urine osmolality. 9.