The first thing to understand about Hypertensive Emergencies is that they look like emergencies
The second thing is in the short term, the only way to really fuck up non-emergent hypertension is by acutely lowering it too much
Hypertensive emergencies, hypertensive urgencies, markedly elevated blood pressure–ugggh! Hypertension is a real annoyance in emergency medicine. Folks get scared of numbers and encourage dangerous behavior because of them. It's a bit better in the ICU, where there is a filter to keep out non-emergent hypertension cases. “Hypertensive Emergencies” are a whole different bag. In these conditions, the hypertension is usually secondary to the actual emergency. So I prefer to call these emergencies with a side of hypertension.
Treatment Priorities
25% in the first hour
- Pain
- Inotropy/Chronotropy
- Arterial Vasodilation
The Meds
- Labetalol
- Esmolol
- Nitroglycerin
- Nitroprusside
- Nicardipine
- Clevidipine
- Fenoldopam
HydralazineSucks
The Emergencies
ACS
SCAPE
- SCAPE Podcast
Aortic Dissection/AAA
- Treatment of Aortic Dissection
Ischemic Stroke
ICH or TBI
aSAH
PreEclampsia/Eclampsia
Hypertensive Encephalopathy/Malignant Hypertension
a headache is not a hypertensive emergency unless the patient looks so bad that you are rushing her to CT
Usually (but not always) will have papilledema
Visual Changes, AMS, Confusion, Severe Headache, Coma
most of these will turn out to be PRES
Tox
Sympathomimetic OD
MAO Inhibitors
Pheo
Acute Glomerulonephritis
Thyroid Storm
Don't Treat Asymptomatic Hypertension
PMID: 37252732
Want More Info?
- Great Htn Review Article from Paul Marik
- Fantastic post from the Strayer
- Long-Term follow-up shows hypertension in ED pts doesn't predict adverse outcome [Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults. Ann Emerg Med. 2021 Feb 9;S0196-0644(20)31363-9. doi: 10.1016/j.annemergmed.2020.11.
005. ]
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My radiology technician will not do a contrast CT if systolic blood pressure > 180 or diastolic >100 because of a protocol written by a radiologist for fear of “causing a stroke.” Is there any literature on this? I was confused the first time they called me on it.
I’m sorry, but that is CRAZY!!!!!
Scott,
Any rationale other than tradition for the 25% over an hour? I guess the places that I would debate that is ICH and acute renal failure “with a side of hypertension”. I think some finesse is required here. I tend to act in a way depending on how chronic the hypertension is
Mike
Hey buddy. The renal failure guys are usually SCAPE, so reduce based on symptom until they can get dialysed. If they are just renal failure and sitting there with a super high bp, then I would argue not an emergency lower as much or as little as you like. ICH does have finesse in my practice. I shoot for 160 in a chronic hypertensive and would go lower in a young person with a TBI. 180 is prob. the agreed max cutoff for ICH, though I don’t see much gain to not just using 160 for them.
I recently had a patient with a STEMI and a BP of 200/110. She was pain free but had nausea and emesis. At what point, if any, is there a benefit to treating hypertension in an AMI. My thoughts being that perhaps at some certain BP that afterload reduction would decrease mvo2 and be beneficial. I cannot find much data or any guidelines on this. Any thoughts?
I can’t find any data either, but we would usually give that patient an ACEI.
and beta blocker for excess sympathetic activation
Great podcast but… in Italy infusional nicardipine is not available so which drug do you suggest for aortic dissection and AAA, ICH and TBI, or eclampsia? Thanks!
Scott, dear boy, We’ve had Clevidipine here in Oz for the past 18-24 months (at least in Wollongong anyway). A pharmaceutical rep’s dream drug; almost overnight replaced labetalol and nitroprusside for hypertensive uneasiness in the ICU. Critical HT is managed in my unit in the various settings pretty much as you outline in your podcast, though I still see hydralazine being reached for as first reaction to unsettling HT. Oh, and while we’re on points over order, “beautifulness” is not a word, it’s “beauty”. Great podcast. Great example of how it IS possible to succinctly cover the key points of… Read more »
Oh dear my friend,
I fear your antipodean dwelling has cut you off from rich vein of your language:
beautifulness
OED hence QED
So happy to hear the ships with 21st century meds have finally made the harsh journey to your distant land. Now, I’m jealous that you’ve managed to skip over nicardipine right to the good stuff. Though it brings the no reason to label the propofol syringes era to a close.
Seriously, thanks for the comments! Hope to see you in Berlin, buddy.
I see elevated BP in another area of the hospital. My pts are post op vascular procedures like carotid endarterectomies, aortofem bypass, Femoral artery endarterectomies and the like. These pt are almost all on betablocker, calcium channel blockers and/or ace inhibitors. There are often told to hold all but betablockers the morning of surgery. After OR and pain is controlled they often have SBP 170-190 with HR in the low 50s. The vascular surgeons do not like restarting acei or calcium channel blockers in the immediate post op period. We often use 10 mg IV hydralazine for this purpose with… Read more »
Bill, great ?
I saw this all the time in the SICU as well. Starting up nicardipine is definitely the way I used to go when the procedure was one where a suture line could blow out if the pt went too high on BP. If that seemed too extreme, then yes sneaking in a little hydral in in ICU where hypotension will be caught is not the worst thing in the world. These pts, unlike the hypertensive emergencies, do not need immediate control.
When referring to ICH/TBI, does this include subdurals and/or epidurals traumatic and/or spontaneous? Is it a good idea to lower BP without ICP monitoring in this situation?
Joel, tough to answer without your job, affiliation, class level, etc.
Sorry,
EM attending, LSU HSC
is it a good idea who the hell knows. is it the accepted standard of care, probably. is it safe, yes we can at least say in ICH that it is (3 studies now of aggressive control <140 with safety)--and systolics >180 are probably harmful in the non-autoregulated brain (first 24 hours in most injuries). Most neurocrit care units are using 140-160 for your subdurals and ICHs. EPidurals, if sig, should be in the or, but I’d use the same goal until then. ICP becomes an issue at the low end, not the high. So keeping the MAP>80 basically gives… Read more »
Scott,
Sidebar-
In the face of DECRA, the Chesnut study and the other most recent craniectomy study, does ICP really matter as much as we think? Sure severe elevations probably matter, but moderate elevations in the face of SDH/Epidurals?
Curious as to how the neurocritical care guys are taking this literature base.
Mike
prob not. though Chestnut is still adamant about monitoring ICP despite his study. Most of neurocrit is based on physiology and opinion
Great podcast! I like the focus on different diagnoses with different treatments (e.g. negative inotropes before vasodilators in aortic dissection). A few remarks: – It seems like microangiopathic hemolytic anemia should be in here (HUS, TTP¨, aHUS, rapidly progressive kidney disease with MAHA, pre-eclampsia can all present with marked hypertension and encephalopathy). – Hypertension is probably not just a side dish in some rare few presentations. Consider a patient with an aortic valvular regurgitation who develops acute pulmonary oedema whenever something startles him. – “The only way to fuck up a non-critically patient with marked hypertension is to acutely lower… Read more »
Great talk. I want to ask about nimodipine ( nicardipine is not available where I work), and another agent dexmedetomidine.
my only experience with nimodipine is as a vasospasm prevention med for aSAH
Alex, MD – Critical Care Unit, Uniklink Hamburg
I have seen some bad cases of hypotension with Nimodipine (both oral and iv) used to treat vasospasms.
Hi Scott
Thanks for the great podcast! I’m a medical officer in South Africa working in an emergency department. We don’t have access to either nicardipine or clovidipine ? What would be an alternative solution?
Thanks in advance
Gen Ferraris
Alex, MD -Critical Care Unit, Hamburg
Great podcast ! It made me look at what options do we have to reduce BP in Germany : metoprolol iv, urapidil iv, dihydralazine iv, nitroG & nitroP and I think that’s about it. Esmolol has only been used once in a septic patient ( 😉 ). Would love to get my hands on those Ca blockers, I will have to check with our Pharmacy lady what is the stand of things in Germany.
Kaitlyn, PA-C; ER – Baltimore, MD Dr. Weingart, Just wanted to say THANK YOU for this segment! Most days as a PA I see the non-emergent patients with ankle pain or something benign in my shop. Most of the staff (such as the triage RN’s) will make the patient wait for a “main side bed” if their pressure is elevated, even when asymptomatic. I argue with them all the time, but I’m just a dumb PA (as they see it) so often the patient still ends up getting a completely unnecessary work-up, simply because of their elevated BP! Hopefully I… Read more »
Scott, Can you post the drug dosage recommendations you discussed for Esmolol and Nicardipine? Thanks
Dr. Weingart, Thank you for this podcast. Although I don’t work in a hospital setting, it is helpful to understand these characteristics when I am evaluating my patients in my occupational health clinic. Often times we will send people to the ER with HTN and no other symptoms because their PCP won’t see them. Many times those cases end up being anxiety attacks. I had one recently like this and I spoke with my medical director via phone ( I am an RN) and we both felt like it was anxiety based on s/s and objective findings, and felt it… Read more »
Greetings and thanks for your great, concise podcasts.
What are you basing your comment “nicardipine is safe in pregnancy” on? Why is it still pregnancy category C if it’s safe in pregnancy?
Thanks in advance. Have a sweet day.
Hypertension causes unhealthy lifestyle and smoking.
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Hi Scott
what about urapidil?
not available US so don’t know