HTN Emergency
(>180/110 WITH end-organ damage)


Terminology sBP dBP  
Normal < 120 < 80  
Pre-hypertension 120-139 80-89  
Hypertension stage 1 140-159 90-99  
Hypertension stage 2 ≥ 160 ≥ 100  
Hypertensive Crisis
(malignant Hypertension)
≥ 180 ≥ 110 NO
end-organ injury
Hypertensive Emergency ≥ 180 ≥ 110 PLUS
End-organ damage

Background

Pathophysiology

Diagnostics

Treatment

  1. Initial/Prep
  2. Medical/Pharmaceutical
  3. Prevention

Disposition

  1. Admit all hypertensive emergencies to be monitored or ICU bed
  2. Admit pts with evidence of end-organ damage
Drug Effects:
Drug BP Pulse Comments
Labetolol α1-, β-Adrenergic blocker
Much more β-blockade than α-blockade
Effective as single agent
Clonidine ↔, ↓↑ Centrally acting α2-agonists, central sympathetic outflow.
Application: hypertension, especially with renal disease (no decrease in blood flow to kidney).
HCTZ ↔, ↓  
Vasotec ↔, ↓  
Hydralazine ↔,↑ Direct arteriolar vasodilator (watch for reflex tachycardia)
Nitroglycerin (reflex response) Venous >> arteriolar dilation
Verapamil, diltiazem conduction velocity, ERP, PR interval.
Used in prevention of nodal arrhythmias (e.g., SVT)
Nicardipene ↔, ↓ Calcium channel blocker
Peripheral vascular resistance
Cerebral vasospasm (good for stroke syndromes)
Phentolamine Pure α-blocker
Orthostatic hypotension, Vomiting, Diarrhea, flushing, wheezing.

Tx By Scenario

Clincal Scenario Goal of Tx 1st line Rx Comments
Hypertensive Encephalopathy 20-25% reduction in MAP over 2-3hr (but keep dBP>100 mmHg) -Nitroprusside 3-4 mcg/kg/minIV (max 10mcg/kg/min x 10min)
-Fenoldopam 0.025-0.3 mcg/kg/min IV, titrate by 0.05-0.1 mcg/kg/min q15min; (max: 1.6 mcg/kg/min); Short term use up to 48 hr
-Clevidipine 1-2 mg/h IV, double rate q90sec until near BP goal, then incr. by smaller increments q5-10min; (max: 32 mg/h, 500 mg/24h)
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)

Diagnosis

  • HA, nausea, vomiting
  • Acute MS changes, confusion, lethargy
  • Focal neurologic deficits, seizures, visual disturbance
  • Fundoscopic findings papilledema, hemorrhages, cotton-wool spots, etc
Treatment may worsen neuro function.
Avoid Clonidine, bb (CNS effects)

 

Ischemic Stroke if BP ?220/120, lower 15-25% in first day -Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Nitropruside, Fenoldopam, NTG may incr. ICP.
Goal: 185/110 if thrombolytics
Intracerebral Hemorrhage Gradually reach 160/80
MAP < 110
CPP >60 w/ ICP monitor
or prestroke level
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nitroprusside 3-4 mcg/kg/minIV (max 10mcg/kg/min x 10min)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Monitor for worsening neuro function after lowering BP
Subarachnoid Hemorrhage same as intracranial hem. -Nimodipine 60mg PO/NGT q4h (to prevent spasm)
+/-
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
AVOID Nitropruside, Fenoldopam & NTG (incr. ICP)
Pulmonary Edema dBP <100 or resolution of Sx -Nitroprusside 0.5-10 mcg/kg/minIV (max 10mcg/kg/min x 10min)
-NTG 5mcg/min IV & incr. 5mcg/min q3-5min until response
-Lasix 40 -80 mg IV x1.
-Morphine 2-5 mg IV
 

AVOID labetalol, diazoxide, hydralazone, minoxidil.

Diagnosis:
  1. DOE, PND, orthopnea, dry cough
  2. Anxiety
  3. Tachypnea, cough, rales/wheezing
  4. Tachycardia, S3/S4 gallop
  5. JVD, peripheral edema
  6. CXR
    • Stage I: pulmonary vascular redistribution to upper lung fields
    • Stage II: interstitial edema
    • Stage III: alveolar edema
  7. ECG changes
  8. Check cardiac markers for myocardial ishcemia

Search for myocardial ischemia. In CAD or PAD, seek RAS

Disposition:

  • Admit to ICU
MI or Unstable Angina dBP <100 or resolution os Sx NTG, BB.
Add SNP if dBP remain elevated
 
Aortic Dissection sBP 100-120 or MAP 80 (watch urine output) -Nitroprusside 3-4 mcg/kg/minIV (max 10mcg/kg/min x 10min)
or
-Clevidipine 1-2 mg/h IV, double rate q90sec until near BP goal, then incr. by smaller increments q5-10min; (max: 32 mg/h, 500 mg/24h)
or
-Fenoldopam 0.025-0.3 mcg/kg/min IV, titrate by 0.05-0.1 mcg/kg/min q15min; (max: 1.6 mcg/kg/min); Short term use up to 48 hr
PLUS
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
Decrease sp/dT, Avoid vasodilator drugs
Sympathomimetic Crisis:
[Cocaine, amphetamines, pheochromocytoma
MAOI reaction
bb or
Clonidine withdrawal]
dBP~ 100-105 (but <25% reduction in presenting BP) over 2-6h -Phentolamine (1st) 5mg IV/IM, then
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)

Benzodiazapine:
- Ativan 1mg IV/IM for cocaine-like drugs.

Alt: NTG +/- CCB
Avoid BB or Labetolol alon (unopposed alpha stimulation)
Restart BB or Clonidine if withdrawing.
Pregnancy (eclampsia) dBP 90-105 or MAP < 126 -Hydralazine 10-20mg IV q30min
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose).
-Nifedipine10-20mg PO
PO: methyldopa.
Avoid: SNP, ACEI
Postoperative PreOp BP SNP, Labetolol, Diuretics Tx pain, Volume overload & decrease O2
Acute renal insufficiency sBP ~ 100-105 (but <25% reduction in presenting BP) Fenoldopam, CCB, BB, Clevidipine, Clonidine. Avoid diuretics. Maintain renal  blood floww
 

Admission Order:
Hypertensive Emergency

1. Admit to:

2. Diagnosis: Hypertensive emergencies

3. Condition:

4. Vital Signs: q30min until BP controlled, then q4h.

5. Activity: Bed rest

6. Nursing: Intra-arterial BP monitoring, daily weights, inputs and outputs.

7. Diet: Clear liquids.

8. IV Fluids: D5W at TKO.

9. Special Medications:

-Labetalol (Trandate, Normodyne) 20 mg IV bolus (0.25 mg/kg), then 20-80 mg boluses IV q10-15min, titrate to desired BP or continuous IV infusion of 1.0-2.0 mg/min, titrate to desired BP.

-Fenoldopam (Corlopam) 0.01mcg/kg/min IV infusion. Adjust dose by 0.025-0.05 mcg/kg/min q15min to max 0.3 mcg/kg/min. [10 mg in 250 mL D5W].

  -Nicardipine (Cardene IV) 5 mg/hr IV infusion, increase rate by 2.5 mg/hr every 15 min up to 15 mg/hr (25 mg in D5W 250 mL).
  -Esmolol (Brevibloc) 500 mcg/kg/min IV infusion for 1 minute, then 50 mcg/kg/min; titrate by 50 mcg/kg/min increments to 300 mcg/kg/min (2.5 gm in D5W 250 mL).
 
  -Phentolamine (pheochromocytoma), 5-10 mg IV, repeated as needed up to 20 mg.
 

10. Symptomatic Medications:

  - Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
  - Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
  - Docusate sodium (Colace) 100-200 mg PO qhs.
  - Zofran 4 mg IV q4h prn n/v.
 
- Famotidine (Pepcid) 20 mg IV/PO q12h  OR
  - Lansoprazole (Prevacid) 30 mg qd.

 

11. Extras: Portable CXR, ECG, echocardiogram.

12. Labs: CBC, CMP, UA with micro. TSH, free T3/T4, 24h urine for metanephrine. Plasma catecholamines, high sesitivity CRP, urine drug screen.