Hypertension

Phone Call

• Why is patient in hospital?

• Is patient pregnant (preeclampsia)?

• How high is BP and what has it been previously?

Phone Call

• Does the patient have symptoms of hypertensive emergency?– Chest/back pain: aortic dissection

– Chest pain: MI

– SOB: PE

– Headache, neck stiffness: subarachnoid hemorrhage

– HA, vomit, confusion, seizure: hypertensive encephalopathy

• What antihypertensive has the patient been on?

Thoughts

• Benign • Hypertensive urgency: SBP>210 or DBP>120 with

no end organ damage• Hypertensive emergency: end organ damage• Life threatening:

– Eclampsia– Aortic dissection– Pulmonary edema– MI– Hypertensive encephalopathy

Bedside Evaluation

• Vitals– BP in both arms: if atherosclerosis artifactually

low, aortic dissection– HR: tachycardia in catecholamine crisis,

bradycardia in increased intracranial pressure

• Symptoms of hypertensive emergency?

Bedside Evaluation

• HEENT: arteriolar narrowing, hemorrhages, papilledema

• Lung: crackles, pleural effusions

• CV: elevated JVP, S3

• Neuro: confusion, delirium, agitation, focal deficits

Management

• Essential hypertension:– In asymptomatic patient no acute lowering of BP

needed

• Hypertensive urgency:– Decrease MAP 25% in hours (can use PO meds)

• Hypertensive emergency:– Call your senior-transfer pt to ICU/CCU

– Decrease MAP 25% in minutes to 2 hours using IV agents

Management

Agent Dose

*Nitroprusside 0.25-10 microgram/kg/min

Nitroglycerine 17-1000 micrograms/min

Labetalol 20-80mg bolus q 10 min or 0.5-2 mg/min

Hydralazine 10-20mg q 20-30 min

Phentolamine 5-15 mg q 5-15 min

IV Agents

*Cyanide toxicity-ms change,lactic acidosis, death

Agent Dose

Captopril 12.5-50 mg

Labetalol 200-1200mg

Clonidine 0.2 mg load, 0.1 mg qh

Hydralazine 10-25 mg

PO Agents