Hypertensive CRISIS

Hypertensive Urgency

  • > 180 systolic or > 120 diastolic WITHOUT ssx of end organ damage

Hypertensive Emergency

  • > 180 systolic or > 120 diastolic WITH ssx of end organ damage

End organ damage:

  • Cardiac

  • Neuro

    • Hypertensive encephalopathy: confusion, seizure, papilledema

    • CVA (ischemic/hemorrhagic)

  • Optic

    • Acute retinopathy ➔ ↓ acuity, flame hemorrhage, papilledema

  • Renal

    • AKI - oliguria (↓ urine production) ➔ anuria (no output), proteinuria, hematuria, hemolytic anemia

Causes

  • Non-compliance

  • Drugs ➔ HTN (stimulants, MAOi and tyramine food), TCAs

  • Hyperthyroid, pheochromocytoma

  • Eclampsia

    • Head/spinal trauma

TX

  • HTN ➔ auto-regulation of vascular beds (get used to high pressure)

  • If BP ↓ too quickly can ➔ ischemic damage

    • Goal: ↓ mean arterial pressure by no more than 25% in first 24hrs

      • UNLESS

        • Ischemic stroke pt that is not candidate for reperfusion

          • Only lower BP if > 220/120

        • Acute intracerebral hemorrhage

          • Call an adult: ↑ pressure ➔ ↑ bleeding but... that ↑ pressure may be needed to perfuse bleeding brain

          • Might want to lower (especially if > 220) to 140-160 (but no less than that)

        • Acute aortic dissection

          • LOWER QUICK: Give β-blocker first! Then vasodilator

            • Vasodilators (nitroprusside) can ➔ rebound tachycardia (esmolol will ⊣ tach)

  • MAP = diastolic pressure + (1/3 x pulse pressure)

    • Pulse pressure = Systolic - diastolic

    • 200/110 ➔ MAP of 140

    • 25% = 35 MAP

      • ↓ MAP 35 is ~ 160/80

AKI pts should not get nitroprusside (↑ risk of cyanate toxicity); anuric ➔ fenoldopam

COPD, asthma, HF, brady should not get β-blockers