HTN Urgency
 (>180/110 WITHOUT 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
  2. Pts w/out evidence of end-organ damage and good f/u can be D/C after initiating therapy
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.

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.

 


References:

JAMA 2003:289:2560; NEJM 2003;348:610; JAMA 2002;288:2981; J Clin Hypertension 2007;9:10; Circulation 2007;115:2761.