EM resident series : HT

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Rajavithi emergency medicine

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EM Residents’ Series : What to do for High BP in ED? : 

EM Residents’ Series : What to do for High BP in ED? Nalinas Khunkhlai,MD. EM faculty Rajavithi Hospital. Review on May 5th,2008

What to do ? : my suggestion : 

What to do ? : my suggestion Check ABC ( coma? Need ETT?) – manage life threatening first. If not … check End-organ damage Heart Neuro Renal Pain anywhere? Pain can drive BP rising. Treat the pain, not BP. HT medication can not relieve the pain. For asymptomatic pt. … did they take their medication today? (mostly seen in HT patient who came from OPD, they NPO themselve for fasting blood test)

Now, Let’s Review the books and evidences : 

Now, Let’s Review the books and evidences We’ll concentrate on ACEP clinical policy Tintinalli online : with update on JNC 7

Definition : 

Definition Ref : JNC 7

But ED approach is based on 4 general categories. : 

But ED approach is based on 4 general categories. Hypertensive Emergency Hypertensive Urgency Acute Hypertensive Episode Transient Hypertension Ref : Tintinalli ed.6th chapter 57 Hypertension

HT Emergency : 

HT Emergency Other terms : Malignant hypertension, Hypertensive crisis HTE is not defined by any absolute BP . HTE = presence of relative BP increase + evidence of target organ injury. Target organs = CNS , Cardiovascular, Renal dysfunction. Ref : Tintinalli ed.6th chapter 57 Hypertension

Slide 7: 

Repeat assessment in both arms if the initial value is elevated. Clinical evaluation Ref : Tintinalli ed.6th chapter 57 Hypertension

Looking for End-organ Damage.. : Neurological system : 

Looking for End-organ Damage.. : Neurological system s/s Headache, diplopia, blurred vision , confusion, hemiparesis, and seizures. PE Mental status : GCS (ddx of HT encep,SAH , stroke) Eyeground : look for hemorrhages, cotton-Wool exudates, Gr.III or IV retinopathy (disc or retinal edema) (Gr.II retinopathy = suggests chr. Uncontrolled hypertension.) Ref : Tintinalli ed.6th chapter 57 Hypertension

Looking for End-organ Damage.. : CardioVascular : 

Looking for End-organ Damage.. : CardioVascular s/s Chest pain, dyspnea (due to heart failure), palpitations. PE Carotid bruits Heart murmur : rt. and lt.side , S3(ventricular failure) , S4 (LVH and noncompliant LV) gallop Pericardial rub Sign of aortic insufficiency Abdomen : AAA Decrease extremity pulses = suspected coarctation or aortic dissection. Ref : Tintinalli ed.6th chapter 57 Hypertension

Looking for End-organ Damage.. : Renal : 

Looking for End-organ Damage.. : Renal s/s Hematuria , Oliguria, Anuria PE No specific exam Ref : Tintinalli ed.6th chapter 57 Hypertension

LAB : 

LAB CBC UA = red cell cast : glomerulonephritis CXR = lt.sided heart failure. BUN, Cr, Elyte, Glucose.(to r/o Hypogly in alteration of conscious) EKG = ST-T change. CT in suspected cases. Ref : Tintinalli ed.6th chapter 57 Hypertension

Slide 12: 

Royal Palace, Thailand

TYPES of Hypertensive Emer. : 

TYPES of Hypertensive Emer. Hypertensive Encephalopathy Stroke Syndromes Acute Pulmonary Edema Acute Coronary Syndromes Aortic Dissection Renal Failure Preeclampsia and Eclampsia Epitaxis Childhood Hypertensive Emergencies Ref : Tintinalli ed.6th chapter 57 Hypertension

Hypertensive Encephalopathy : Fact : 

Hypertensive Encephalopathy : Fact Acute and reversible. Occur when MAP overwhelm cerebral autoregulation..usually MAP above 150-160 mmHg. Severe headache + N/V + may alter mental status. ( confusion, drowsy , seizure , VA drop, focal deficit, comatose) Hypertensive Retinopathy Gr. 3-4 (III-IV) Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Hypertensive Encephalopathy : DDx : 

Must Rule out ICH Stroke Hypertensive Encephalopathy : DDx Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Hypertensive Encephalopathy : Treat ! : 

GOAL : reduce BP 20-25 % (help reverse cerebral vasospasm) BUT EXCESSIVE reduction must be avoided. Hypertensive Encephalopathy : Treat ! Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Stroke Syndromes : Fact : 

Stroke Syndromes : Fact Stroke pt. commonly have physiologic response to maintain cerebral perfusion. ICH commonly profound BP rising. Acute management of BP associated with ICH is controversial. SAH : nimodipine 60mg q 4hr. (recommend Oral) to reverse the vasospasm associated with SAH Or Nicardipine Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Acute Pulmonary Edema : Fact : 

Acute Pulmonary Edema : Fact Abrupt BP rising cause acute LV failure. (increase afterload) Nitroprusside and IV NTG are the agents of choice to reduce BP. Other treatment for Pulmonary Edema : Nitrate , O2 , Diuretic , Morphine Trick : You can use Nitroderm patch but have to closely monitor the pt. Rapid remove when achieve the desired BP target. Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Acute Coronary Syndromes : Fact : 

Acute Coronary Syndromes : Fact Increase LV EDP (end-diastolic pressure)  increase workload of heart. Nitroglycerin (SL or IV) Then consider Nitroprusside for greater pressure reduction. Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Aortic Dissection : Fact : 

Aortic Dissection : Fact Reducing BP can limit the extent of dissection Aim to reduce the ventricular ejection force. Give Betablock (esmolol) + Nitroprusside or labetelol alone. Emergency CVT consultation while medically manage Surgical intervention is indicated in dissection when involving the ascending aorta or aortic arch. Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Renal Failure : Fact : 

Renal Failure : Fact CKD pt can show High BP and poorly control itself. Management for HT emer with renal failure as end-organ damage should be considered very carefully. Clues : BP shoot + oliguria + UA(proteinuria, RBC and red cell cast) + BUN,Cr rising. In patient with sign of volume overload, emergent dialysis may require Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Epistaxis : Fact : 

Epistaxis : Fact Association remains controversial Not the definition of end-organ dysfunction Most are only Hypertension , not hypertensive emergency When question , repeat physical exam and look for sign or Neuro-Heart-Kidney damage Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

Childhood Hypertensive Emer: Fact : 

Childhood Hypertensive Emer: Fact Uncommon , <5% Definition : SBP or DBP > 95th percentile for age in growth graph Renal – Renovascular disease – and pheochromocytoma are the most common etiologies. Non specific symptom ex.throbbing headache Decision to treat is based on BP shoot + symptom GOAL : reduce 25% in 1 hr. Nitroprusside , labetalol are the agents of choice Admission require. Ref : Tintinalli ed.6th chapter 57 Hypertension TYPES of Hypertensive Emer.

TREATMENT : Hypertensive Emer : 

Ref : Tintinalli ed.6th chapter 57 Hypertension TREATMENT : Hypertensive Emer

Slide 25: 

Ref : Tintinalli ed.6th chapter 57 Hypertension

Slide 26: 

Ref : Tintinalli ed.6th chapter 57 Hypertension

Recommendation : What Meds we have in our hospital : 

Recommendation : What Meds we have in our hospital Nicardipine : 10 mg/amp Suggest : concentration 1 : 10 (= nicardipine 1 amp or 10mg + NSS 100 ml.) Start titrate at 1 mg/hr. first Observe BP very closely REMEMBER the GOAL : don’t take down more than 20-25% Recheck Neuro sign : especially focal weakness (stroke) frequently

Others.. : 

Others.. Hypertensive Urgency : less clearly defined. Acute Hypertensive Episode : for JNC VI, define as stage 3 HT without organ damage. But from JNCVII, read ACEP policy for asymptomatic hypertension. Transient Hypertension : association with conditions ex. Anxiety Alcohol-withdrawal syndromes Sudden cessation of Medications Some toxic substances Ref : Tintinalli ed.6th chapter 57 Hypertension

Others.. : 

Others.. “White-coat hypertension” = a phenomenon that pt has BP shoot at clinical setting but has a normal pressure at other times. Normotensive after f/u 24hr. Ref : Tintinalli ed.6th chapter 57 Hypertension

TREATMENT : Hypertensive Urgency : 

Ref : Tintinalli ed.6th chapter 57 Hypertension TREATMENT : Hypertensive Urgency GOAL : gradual reduction of BP within 24h by using oral antihypertensive agents Common cause of HT urgency is noncompliance with medications , so..restarting pt’s previous med is an acceptable strategy. F/u in 24hr. should be arranged. Admission? : depends on comorbid conditions or pt.

TREATMENT : Hypertensive Urgency : 

Ref : Tintinalli ed.6th chapter 57 Hypertension TREATMENT : Hypertensive Urgency

TREATMENT : Hypertensive Urgency : 

Ref : Tintinalli ed.6th chapter 57 Hypertension TREATMENT : Hypertensive Urgency May I remind you the GOAL again !! = gradual reduction of BP within 24h by using oral antihypertensive agents Wait for lab if you’re not sure. Like Cr. Be careful on “compromizing risk”

Do you own further reading in Tintinalli 6th ed. : 

Do you own further reading in Tintinalli 6th ed. About Acute Hypertensive episode And other conditions.

Another useful table. : 

Another useful table. Ref : Tintinalli ed.6th chapter 57 Hypertension

Slide 37: 

FAQ : (frequently asked questions)

What should I do ? For Asymptomatic patient : 

What should I do ? For Asymptomatic patient FAQ : (frequently asked questions) “…I’ve got a man with BP 240/100 mmHg. Come for annual check up, OPD nurse sent him to ED. He looks OK. Can talk to me, full conscious, no dyspnea, EKG ok, void normally. Do I have to work up or can I send him home? Or he needs admission?...Should I take labs?....”

Slide 39: 

FAQ : (frequently asked questions) “…I’ve got a man with BP 240/100 mmHg. Come for annual check up, OPD nurse sent him to ED. He looks OK. Can talk to me, full conscious, no dyspnea, EKG ok, void normally. Do I have to work up or can I send him home? Or he needs admission?...Should I take labs?....” ANS : If this is 1st diag, He’s work up in ED (CBC,UA,Elyte,BUN,Cr, EKG) (no need for cardiac enz if asymptomatic and good Functional class , I leave it to your judgment.) Treat on Oral medication, no aggressive IV Med needs

Slide 40: 

And these’re the literature…..

Resources : 

Resources ACEP Clinical Policy : Critical Issues in the Evaluation and Management of Adult Patients With Asymptomatic Hypertension in the Emergency Department. Approved by the ACEP Board of Directors, September 23,2005. Published in Annals of Emergency Medicine Vol47, NO.3 : March 2006 Tintinalli Chapter 57 Hypertension. Lastest Update 04-10-08 : Asymptomatic Hypertension in the Emergency Department : First, DO NO HARM.

Statement : 

Statement

Definition : 

Definition Ref : JNC 7

Slide 44: 

Ref : ACEP clinical policy

Evidence-based medicine : Literature on Therapy : 

Evidence-based medicine : Literature on Therapy RCT is the best evidence of literature on therapy Then Observational study is the second.

Level of recommendation : 

Level of recommendation

So it was made for… : 

So it was made for…

Critic : 

Critic

Critic (cont.) : 

Critic (cont.)

Critic (cont.) : 

Critic (cont.)

สรุปสำหรับข้อสอง : 

สรุปสำหรับข้อสอง

Relevance to Emergency Medicine Practice : 

Relevance to Emergency Medicine Practice JNC7 : repeat measurement 2 times..at least 5 min. rest. Pt with Stage2 HT + no end organ damage = should be “evaluated or referred to source of care within 1 month. Asymptomatic High BP (>180/110mmHg) = evaluate and treat immediately or within 1 wk. depending on clinical situation and complications. Ref : Tintinalli Chapter 57 Hypertension. Lastest Update 04-10-08 : Asymptomatic Hypertension in the Emergency Department : First, DO NO HARM.

Relevance to Emergency Medicine Practice : 

Relevance to Emergency Medicine Practice Lowering BP in Asymp. Pt with NO evidence of target organ damage MAY DANGEROUSLY . Current evidence : most issues in f/u ,initiation, reinforcement or adjustment of OPD anti-HT medication. AND issues on regimen compliance. Ref : Tintinalli Chapter 57 Hypertension. Lastest Update 04-10-08 : Asymptomatic Hypertension in the Emergency Department : First, DO NO HARM.

What to do ? : my suggestion : 

What to do ? : my suggestion Check ABC ( coma? Need ETT?) – manage life threatening first. If not … check End-organ damage Heart Neuro Renal Pain anywhere? Pain can drive BP rising. Treat the pain, not BP. HT medication can not relieve the pain. For asymptomatic pt. … did they take their medication today? (mostly seen in HT patient who came from OPD, they NPO themselve for fasting blood test)

Questions ? : 

Questions ? Send it to nalinas@narenthorn.or.th Thank you for your attention. Royal Palace, Thailand

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