MANAGEMENT OF HYPERTENSIVE EMERGENCIES BY DR ISAAC.pptx

Aim is to aid medical practitioner give efficient medical care to hypertensive patients with hypertensive emergency in order to prevent morality associated with this clinical condition

1. MANAGEMENT OF HYPERTENSIVE EMERGENCIES BY DR. IME ISAAC.

2. OUT LINE INTRODUCTION DEFINITION OF TERMS ETIOLOGY AND PATHOPHYSIOLOGY COMPLICATIONS CLINICAL PRESENTATION MANAGEMENT CONCLUSION

3. INTRODUCTION HYPERTENSION is the most common modifiable risk factors for cardiovascular disease and it is also one of the commonest cause of increased mortality in AFRICA , about 60million blacks develop hypertension and approximately 1-2% develop hypertensive emergency with end organ damage. Race : African/African Americans have higher incidences of hypertensive emergencies than Caucasians. Sex: Males are at greater risk than females. Age : Most commonly seen in middle aged people , peak 40-50years.

4. DEFINITION OF TERMS HYERTENSIVE EMERGENCY : is characterized by severe increase in systolic and/or diastolic blood pressure associated with signs and symptoms of acute end organ damage. Usually; SBP> 180-220MMHG DBP> 120-130MMHG MAP>180MMHG (MAP=DP+1/3 PP) HYPERTENSIVE URGENCY : Is characterized by severe elevation of BP > 180/120MMHG without symptoms or signs of acute target organ involvement.

5. ETIOLOGY PRIMARY HYPERTENSION : Essential Hypertension: Inadequate blood pressure control or noncompliance ( most common ). SECONDARY HYPERTENSION : PREGNANCY: Eclampsia / Severe pre-eclampsia. ENDOCRINE CRISIS : PHEOCHROMOCYTOMA AND HYPERTHYRIODISM HEAD INJURIES CEREBROVASCULAR INFARCTS / HEMORRHAGE RENAL: RENINE- SECRETING TUMORS RENOVASCULAR DISEASE Eg ; Renal Artery stenosis, Atherosclerotic renovascular dx, SLE DRUG INCLUCED HYPERTENSION Eg ; CAFFEINE , PREDNISOLONE ,CYCLOSPORINE ETC ILLICT DRUG USE( COCAINE, PHENCYCLIDINE AMPHETAMINES) POST –OP HYPERTENSTION

6. PATHOPHYSIOLOGY Normal Autoregulation = Rise in BP Arterial & Arteriolar constriction Normal blood flow (flow = p/r) Autoregulation Failure = Rise in BP Failure of Vasoconstriction Endothelial damage (due to shear stress on the wall of arteries and arterioles) Deposition of protein and fibrinogen in the vessels wall Activation of coagulation and inflammation cascade Fibrinoid necrosis.

7. EFFECT ON THE SYSTEM CNS: Failure of vasoconstriction failure of auto-regulation of cerebral blood flow transudate leak across the capillary and continuous arteriolar damage and necrosis papilledema (clinical apparent) Hypertensive Encephalopathy. CVS: Failure Vasoconstriction Increase Cardiac work load Cardiac failure( Pulmonary Edema, Myocardia Ischemia and Infarction). RENAL SYSTEM: Failed auto-regulation Impaired renal control of extracellular volume and perfusion pressure Renal failure.

8. COMPLICATIONS CNS: Hypertensive encephalopathy, ICH or SAH, Ischemic Stroke, TIA CVS: Acute pulmonary edema( LVF), Acute congestive cardiac failure, Acute coronary ischemia( Myocadiac infarction or unstable angina). RENAL: Acute Kidney failure. LIVER: HELLP Syndrome. OCCULAR: Retinal hemorrhage VASCULAR: Eclampsia, Aortic dissection

9. CLINICAL PRESENTATION Elevated BP + CNS : Delirium, seizures, altered consciousness, focal deficit, Papilledema , throbbing headache, Blurry vision (Hypertensive Encephalopathy or Hemorrhage Stroke or Ischemic Stroke) Cardiorespiratory system : Dyspnea, orthopnea, Cough, Peripheral edema, PND (Pulmonary edema/ congestive cardiac failure) :Ripping back pain, tearing chest pain ( aortic dissection/ acute MI) GIT Nausea, vomiting, (ICP) Renal : Hematuria, Azotemia, Oliguria Persistent nose bleeding

10. MANAGEMENT INVESTIGATIONS BLOOD WORKUP : FBC , SERUM E/U/CR, BLOOD GLUCOSE, SERUM CALCIUM, NITROGEN, CARDIAC EMZYMES, LIVER FUNCTION, SERUM PT. RADIOLOGY : ECG , CHEST XRAY, AORTIC ANGIOGRAM, BRAIN CT, CHEST CT/ MRI , EKG, ABDOMINOPELVIC USS. TOXICOLOGY

11. TREATMENT RESUSCITATION Like all emergency cases prompt and efficient intervention is the hallmark ABCD of resuscitation should be instituted immediately. In hypertensive emergency resuscitation and quick clinical evaluation ( precise history taking and examination ) is done simultaneously, aimed at identifying ongoing organ damage ESSENTIAL HX: HX of antihypertensive use and compliance, illicit drug use, Duration of presenting symptoms, LMP, Any other medical condition CLINICAL EXAMINATION is based on organ system CNS :Access for focal deficit, GCS, CVS : HR PR JVP Peripheral edema RS : Breath sounds ABDOMEN : Masses and bruit

12. TARGET BP IS AIMED AT REDUCING BP TO 25% OF PRESENTING BP IN THE 1 ST 8-12HOURS THEN 25% IN THE NEXT 8-12HRS FINALLY 50% OVER 24HOURS WHILE MAP REDUCED BY 20% - 25% IN THE IST HOUR VASODILATORS DRUG DOSAGE ONSET/DURATION SIDE EFFECT MEDICAL CONDITION Nitroprusside 0.25-10mcg/kg/min Instant/1-2min Cyanide Poisoning Post op hypertension, Aortic dissection, pheochromocytoma Hypertensive Encephalopathy Nitroglycerine 5-100mcg/min 1-5min/3-5min Flushing, headache, methemoglobin Post op hypertension, Acute LVF, MI/ Unstable angina Nicardipine 5-10min/ hr 5-10min/1-4hr Tachycardia, flushing Eclampsia/severe preeclampsia, MI/Unstable angina Hypertensive encephalopathy Hydralazine 10-20mg 5-15min/ 3-8hr Tachycardia, flushing Eclampsia/severe preeclampsia Enalapril 10-40mg IM , 1.25-5MG IV 20 -30min/6hr Hypotension, Renal Failure, Hyperkalemia Acute LVF

13. ADRENERGIC INHIBITORS DRUGS DOSAGE ONSET/DURATION SIDE EFFECT MEDICAL CONDITION Labetalol ( a+b blocker) 20-80mg iv bolus-10min 0.5 -2.0mg/min IV infusion 5 -10min/3-6hrs Heart block, Orthostatic hypotension MI/Unstable angina, Hypertensive encephalopathy, ICH or SAH, Aortic dissection, post op hypertension, Eclampsia Esmolol (b-1 selective blocker) 200-500mcg/kg/min for 4min then 150-300mcg/kg/min 1-2min/10-20min HYPOTENSION MI /Unstable Angina Phentolamine (a1blocker) 5-15mg iv 1-2min/3-10min Tachycardia, Headache Adrenergic crisis/ pheochromocytoma Furosemide*** (loop diuretic) 20-80mg IV/IM 5min/2hrs Headache , blurred vision, dizziness Acute pulmonary edema, Acute congestive cardiac failure, ICP, Acute renal failure ORAL MEDICATIONS Captopril(ACE inhibitor) 6.25-25MG 15-30min/6hr Hypotension Clonidine(a2 agonist , centrally acting 0.1-0.2mg hrly to max 0.8mg in 24hrs 30-60min/6-12hrs Sedation, Bradycardia, dry mouth Labetalol 100-200mg 30 -120min/8-12hrs Heart block, bronchospasm Nifedipine(ca channel blocker 10-30 to max 60mg/day 20min/8-24hrs Dizziness, headache, ankle/feet swelling

14. SUPPORTIVE CARE INTENSIVE CARE UNIT NURSING VENTILATORY SUPPORT FOR COMATOSE PATIENT INTERMITTENT AIRWAY SUCTION OF PATIENT WITH SIGNS OF ASPIRATION OXYGEN SUPPLEMENTATION OF CONSCIOUS PATIENT WITH LOW O2 SATURATION OTHER MEDICATIONS :IV HYDROCORTISONE (PX WITH BRONCHOSPASM) :IV ANTIBIOTICS /ANALGESIC/ANTACIDS/ANTICONVULSANT /ANTI THROMBOLYTIC DIALYSIS FOR RENAL FAILURE BLOOD TRANSFUSION ADEQUATE NUTRITION AND GOOD HYGIENE MONITORING AND REGULATING FLUID INPUT AND OUTPUT REGULAR MONITORING OF VITALS SIGNS AND GLUCOSE LEVEL SURGICAL INTERVENTION IF REQUIRED PHYSIOTHERAPY AND PYSCHOTHERAPY

15. CONCLUSION Follow-up review with the cardiologist, Nephrologist and other specialists post hospital discharge is essential for prevention of reoccurrence of this life threatening medical condition.