Approach to Hypertensive Crises in ED

Dr Mohammad Zikri Ahmad Emergency Resident HUSM

Hypertension is classified into prehypertension, stage I and stage II hypertension

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Hypertensive crises is a critical elevation in the BP with markedly elevated diastolic BP ( !"# $"mmHg% which incl&des HP' Emergency and (rgency

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Hypertensive Emergencies is a spectr&m of clinical presentation where &ncontrolled BPs lead to progressive or impending end#organ dysf&nction)damage

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Ac&te end#organ damage may incl&de ne&rological, cardiovasc&lar, renal, retinopathy, or eclampsia

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Hypertensive &rgency* severe elevated BP associated with imminent E+D

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,ook for patients with end organ damage and re-&ire immediate I. therapy
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The EP must be capable of treating the patient and not the number

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It is a prod&ct of failed a&toreg&lation, a/r&pt rise of 0.1 and release of vasoconstrictors

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2ost commonly presents with C.A, p&lmonary oedema, hypertensive encephalopathy and CC3

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Cere/ral a&toreg&lation is the a/ility of the cere/ral vasc&lat&re to maintain a constant (CB3% across a wide range of perf&sion press&res4

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1apid rises in /lood press&re can ca&se hyperperf&sion and increased CB3, which can lead to increased intracranial press&re and cere/ral edema45 6

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The left ventricle is unable to compensate for an acute rise in SVR that leads to left ventricular failure and pulmonary edema or myocardial ischemia.[4 ]

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hen renal autoregulatory system is disrupted! intraglomerular pressure starts to vary directly "ith the systemic arterial pressure! thus offering no protection to the #idney during $P fluctuations % this can lead to acute renal ischemia.[4 ]

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&eath from both ischemic heart disease and stro#e increase progressively as the $P increases
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3+C(0 History, Physical E7aminations, Investigations and 'reatments

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'ake a thoro&gh medication history to assist in treatments

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Assess whether specific symptoms s&ggesting E+D(s% are present

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0imilarly, physical e7aminations are to assess whether E+D is there

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2ost patients have a history of inade-&ate hypertensive treatment or an a/r&pt discontin&ation of their medications

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Don8t forget other ca&ses9

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Acute Coronary Syndrome

Stroke, schemic Dissection, Aortic

Migraine Headache Aneurysm, Abdominal Myocardial n!arction

Subarachnoid Hemorrhage

Encephalitis

An"iety

Systemic 'upus Erythematosus (lomerulonephritis, Acute &o"icity, Amphetamine Headache, Cluster &o"icity, #hencyclidine Headache, &ension

#regnancy, Eclampsia

Congesti$e Heart %ailure and #ulmonary Edema

#regnancy, #reeclampsia Cushing Syndrome Stroke, Hemorrhagic Delirium &remens

Hyperthyroidism, &hyroid Storm, and (ra$es Disease

Differential Diagnoses

:o& may want to consider other ca&ses;

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Perform o/<ective la/ st&dies

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And a foc&sed radiological st&dies;

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=ell, EC> is a 2(0'9

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2anaging /egins with correct differentiation of &rgency and emergency

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Misconception * a patient never sho&ld /e discharged from the ED with an elevated BP

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Ac&te lowering of BP in the narrow window of the ED visit does not improve long#term mor/idity and mortality rates

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2AP sho&ld /e lowered /y no more than !"? in the first ho&r of treatment, then /e lowered to @") ""# " mm Hg in the ne7t !#@ ho&rs if sta/le

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E7ceptions* Hypertensive encephalopathy warrants !A? 2AP red&ction over B ho&rs

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Don8t treat BP in ac&te ischemic stroke &nless C!!") !" +1 yo& want to give fi/rinolysis

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'reat Ac&te ICB more aggressively with target 0BP D"mmHg for E days
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2aintain 0BPF @"mmHg in 0AH &ntil definitive management and add Gimodipine

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Aggressively treat dissecting ane&rysm with target 0BPF "mmHg

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In AC0, treat if BP C @") ""mmHg /y !"#$"? /aseline red&ction

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.asodilators and nitroglycerin is the preferred agent for ac&te heart fail&re
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Cocaine to7icity associated HP' and tachycardia doesn8t re-&ire specific treatment /&t alpha#adrenergic antagonists to /e given once AC0 kicks in

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(se HydralaHine and 2agnesi&m 0&lfate in pre)eclampsia

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All hypertensive emergency cases need cons&ltation whereas hypertensive &rgencies m&st have an early follow &p

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Admit HP' emergency cases to intensive care &nit for close monitoring
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Discharge HP' &rgency patients with long term care plan

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3ollow Gational Committee on High Blood Press&re recommendations

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'ransfer patients to higher level of care if necessary

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Always watch o&t for complications and treat it like a ticking time /om/

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EI? of &ntreated HP' emergencies die in year

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3ail&re of 3+C(0 will lead to litigation holoca&st9

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'hank :o&
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Dr&g Apppendi7
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1eferences
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