HYPERTENSIVE
CRISIS
Definitions:
1. Urgent hypertensive crisis: diastolic
BP>120-130 mmHg
2. Hypertensive emergency: severe elevation
in BP w/ evidence of acute or ongoing end-organ damage, which may include-
a. CNS- encephalopathy: HA, nausea, vomiting, visual
disturbances, confusion, focal or general weakness, disorientation,
obtundation, focal neurologic signs, seizures, retinopathy/papilledema,
asymmetric reflexes, nystagmatus; infarction; hemorrhage.
b. CV- myocardial ischemia/infarction, LV
failure, aortic dissection
c. RENAL- ARF
Causes: exacerbation of chronic HTN,
renovascular/parenchymal renal disease, collagen-vascular disease, drugs
(cocaine, amphetamines, phencyclidine, LSD, diet pills, TCA), withdrawl from
antihypertensives, pre/eclampsia, pheo, AGN, head injury, tyrmaine
ingestion+MAO, renin-secreting tumor, vasculitis, GBS/other spinal cord
syndrome.
Treatment:
GOALS-
1. Urgent hypertensive crisis: gradually reduce
BP over 24-48 hrs. Place pt in dark,
quiet room, remeasure BP in 30 min. IF
still elevated, initiate PO therapy.
2. Hypertensive emergency: reduce BP 25%
(diastolic 100-110 mmHg) over minutes to hours.
TREATMENT BY TYPE OF END-ORGAN DAMAGE
|
Type |
Treament |
Avoid |
|
Encephalopathy |
NTPrusside, labetolol, diazoxide |
Beta-blk, m-dopa, clonidine |
|
Cerebral infarct |
No rx, NTPrusside, labetalol |
Beta-blk, m-dopa, clonidine |
|
ICH, SAH |
No rx, NTPrusside, labetalol |
Beta-blk, m-dopa, clonidine |
|
MI/ischemia |
TNG, labetalol, CCB, NTPrusside |
Hydralazine, diazoxide, minoxidil |
|
Pulm edema |
NTPrusside $ lasix, TNG & lasix |
Hydralazine, diazoxide, beta-blk, labetalol |
|
Ao dissection |
NTPrusside & beta-blk, trimethaphan &
beta-blk, labetalol |
Hydralazine, diazoxide, minoxidil |
|
Eclampsia |
Hydralazine, diazoxide, labetalol, CCB |
Trimethaphan, diuretics, beta-blk |
|
ARF |
NTPrusside, labetalol, CCB |
Beta-blk, trimethaphan |
|
Grade III-IV Keith-Wagener |
NTPrusside, labetalol, CCB |
Beta-blk, clonidine, m-dopa |
|
Microangiopathic hemolytic anemia |
NTPrusside, labetalol, CCB |
Beta-blk |
PARENTERAL MEDS
|
Drug |
Onset |
Duration |
Dose |
|
NTPrusside |
immed |
2-3 min |
0.5-10 mcg/kg/min (0.35 for eclampsia or RF) |
|
Diazoxide |
1-5 min |
6-12 hrs |
50-100 mg Q5-10 min up to 600 mg OR 10-30 mg/min CI |
|
Labetalol |
5-10 min |
3-6 hrs |
20-80 mg Q 5-10 min up to 300 mg |
|
TNG |
1-2 min |
3-5 min |
5-100 mcg/min |
|
Phentolamine |
1-2 min |
3-10 min |
5-10 mg Q5-15 min |
|
Trimethaphan |
1-5 min |
10 min |
0.5-5 mg/min |
|
Hydralazine |
10-20 min |
3-6 hrs |
5-10 mg Q20 min |
|
Nicardipine |
1-5 min |
3-6 hrs |
5 mg/hr, incr 1-2.5 mg/hr Q15 min up to 15 mg/hr |
Calhoun, Oparil. NEJM. 323(17): 1177-83, 1990.