Archive for the ‘.hypertension’ Category

  There are two kinds of hypertension encountered by emergency physicians: hypertensive emergencies, and hypertension. The term hypertensive urgency has minimal meaning, less than minimal utility, and should be abandoned. Patients with a hypertensive emergency are critically ill. They need to be in a resuscitation area on intravenous antihypertensive drips. The hypertensive emergencies are acute pulmonary edema, aortic dissection, preeclampsia, subarachnoid hemorrhage, and hypertensive encephalopathy. Intravenous blood pressure reduction may also be indicated in acute coronary syndrome, acute ischemic stroke, and intracerebral hemorrhage. A patient with severe hypertension and arterial bleeding unable to be staunched using conventional means perhaps qualifies as a hypertensive emergency and it may be reasonable to use IV medications to lower blood pressure in these patients as well; however, if allowed to take its natural course, hypertension in these cases will surely be self-limited. Acute renal failure is always included in the list of hypertensive emergencies, but no one knows what to do with this because while it is clear that longstanding hypertension can box your kidneys, the relationship of the elevated creatinine in the patient in front of you to the hypertension in the patient in front of you is usually impossible to determine. If an acutely ill patient has very high blood pressure and an elevated creatinine that is not known to be old, it is reasonable to treat that patient as a hypertensive emergency. A well patient with hypertension and an elevated creatinine needs to be in an internist’s clinic, not in the emergency department. There are a…

  This post has been superseded by this one.   All BP values are linked with or as in SBP of 220 or a DBP of 120. No end organ damage Administering antihypertensive therapy in the ED for the purpose of acutely lowering blood pressure in patients without end-organ damage is discouraged. Commence oral antihypertensive therapy if BP > 200/120. Consider commencing oral therapy if BP > 180/110. A basic metabolic panel is recommended before starting a patient on antihypertensives. Avoid ACE inhibitors in woman of childbearing potential. All hypertensive patients require follow-up. Acute Ischemic Stroke not being treated with thrombolysis Unless concomitant condition requiring BP control, do not treat until over 220/120. Keep above 140/90. Use labetalol or nicardipine. Spontaneous Intracerebral Hemorrhage not SAH If signs of high ICP, keep MAP below 130 or SBP below 180. If no signs of high ICP, keep MAP below 110 or SBP below 160. Use labetalol, nicardipine, or esmolol. Subarachnoid Hemorrhage Keep SBP below 160 until clipped or vasospasm occurs. Use labetalol, nicardipine, or esmolol. Oral nimodipine is used for vasospasm prophylaxis, not treatment of hypertension, though it may lower blood pressure. Traumatic Brain Injury Do not treat hypertension. Keep CPP between 50 and 70, but do not use vasopressors. Acute Coronary Syndrome Reduce by 20-30% if > 160/100 with IV/SL nitro or beta blocker. Avoid thrombolytics if > 185/110 Heart Failure / Pulmonary Edema Treat hypertensive and normotensive pulmonary edema patients with IV/SL nitro or ACE inhibitor. Hypertensive encephalopathy Reduce MAP by 25% over eight hours with labetalol,…

nicardipine = cardene enalaprilat = vasotec

esmolol = breviblock phentolamine = regitine

labetolol = trandate = normodyne