Management of Hypertension and Hypotension in the Emergency Department. Hypertension. How do we manage Hypertension in the ER??. Hypertension Management in the ED. Annual Census = 78,000 patients Approximately 215 patients per day
How do we manage Hypertension in the ER??
First Step: Department
Categorize Types of
- Hypertensive Emergency
- Hypertensive Urgency
- Acute Hypertensive Episode
- Transient Hypertension
What is a Hypertensive Department
- A relative increase in blood pressure from baseline combined with Target Organ Dysfunction (TOD)
How do we define Department
Target Organ Dysfunction
Evidence of Damage or Injury to “Target Organs” such as the Heart, Brain, Lungs, Kidneys, or Aorta.
How do we determine if Department
Target Organ Dysfunction
1. EKG: (Evaluation for ST elevation or depression, new T-wave inversions, LVH, or new Left BBB)
7. CT Head: (only if neurological findings are suspicious for acute CVA)
Diagnosis and Management Department
- Loss of Cerebral Autoregulation of blood flow resulting in hyperperfusion of the brain, loss of integrity of the blood brain barrier, and vascular necrosis.
Headache, Nausea/Vomiting, Lethargy,
Confusion, Lateralizing neurological symptoms
that are not often in an anatomical distribution.
Papilledema, Retinal Hemorrhages
Decreased level of consciousness, Coma
Focal neurological findings
- Nitroprusside is the agent of choice (T.397) and (R.1759)
- Nitroglycerin and Labetalol have been used successfully, but have not replaced Nitroprusside
Management of Ischemic Department
Elevated Blood Pressure can be the cause of the central nervous system event, OR, it may be a normal physiologic response (Cushing’s Reflex)
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.
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.
Rosen: In most cases, recommends no treatment of Hypertension in CVA patients.
- However, the author does recommend treating HTN if diastolic blood pressure is greater than 140 mmHg.
Management of Department
Management of CHF/ Department
Increased Afterload with decreased Cardiac Output
Shortness of Breath, Cough, Chest Pain
Lower Extremity Swelling
Jugular Venous Distension, Rales, S3 Gallop
Hepatomegaly, Pedal Edema
Management of Acute Department
- Increased afterload, cardiac workload, and myocardial oxygen demand
- Decreased coronary artery blood flow
Chest Pain, Nausea / Vomiting, Diaphoresis,
Shortness of Breath
Congestive Heart Failure Signs,
(due to decreased ventricular compliance)
Few physical findings in many patients
Clinical History is very Important
Nitroglycerin IV or Sublingual (T. 398)
Nitroprusside (T. 398)
Beta Blockers (Esmolol,Lopressor) (T. 356-357)
Nitroglycerin is Drug of Choice (R. 1761)
Dissection of Department
- 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.1762-3)
- Differential Blood Pressure (in UE)
Optimal Blood Pressure in these patients is undefined and must be tailored for each patient, however,
SBP of 120-130mmHg may be a intial starting point. (T.408)
Acute Renal Failure Department
- 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.
- Many times there are few actual symptoms
- Alpha and Beta stimulation of the cardiovascular system due to adrenergic excess states
Episodic Headaches, flushing, tremor, diaphoresis, diarrhea, hyperactivity, and palpitations
Tachycardia, tachypnea, tremor, hyperdynamic state (high output CHF)
Toxemia of Pregnancy Department
Lower extremity swelling, headache, confusion, seizures, coma
Edema, hyperreflexia, elevation of blood pressure related to baseline BP prior to pregnancy (elevation may be mild 125/75)
- 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)
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)
- 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)
What is a Hypertensive Department
- 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)
(Tintinelli pg. 402)
What is an Acute Department
Elevation of Blood Pressure relative to baseline, but WITHOUT evidence of acute OR impending Target Organ Dysfunction (TOD)
What is Transient Department
SWITCHING GEARS Department
Management in the ED
Types of Shock:
(inadequate circulating volume)
(inadequate pump function)
(extra-cardiac obstruction of blood
1. Determine Cause:
- Usually very apparent
- Can be subtle
- No single Vital Sign that is diagnostic of Shock
- Initial Therapy guided by clinical findings
2. Evaluate Signs and Symptoms:
- Decreased Urine Output
- Cool, Mottled Skin
A- Secure Airway (intubate if needed)
B- Insure oxygenation and ventillation
C- Provide Hemodynamic Stabilization (correction of hypotension based on etiology)
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
It is not unusual for a patient to require 4 to 6 Liters of fluid in the initial phase of resuscitation.
If 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.
Questions ??? Department