Hypertensive Urgency and Emergency

# Hypertensive Urgency/Emergency
Checklist
-- Gut Check: manual BP with correct sized cuff, check on both arms
-- ABCs: is there end-organ dysfunction suggesting emergency and need for ICU for a-line and close monitoring and titration of antihypertensives?
‍-- Chart Check: usual BP range, home BP meds, co-morbidities (CAD, CHF, CKD/ESRD)
-- Admission Criteria: evidence of end-organ dysfunction
-- HPI Intake: missed HTN meds, missed dialysis, drug use, pain, anxiety, headaches, visual changes, dyspnea, chest pain, oliguria
-- Can't Miss: red flags - dyspnea, chest pain, AMS, focal neuro symptoms
-- Admission Orders: CBC, CMP, UA, trop, BNP, EKG, CXR; consider tele, UDS, CTA Chest, CT head; restart home HTN regimen if applicable
-- Initial Treatment to Consider: IV vs. PO medications - usually labetalol unless ACS, CHF

Intake
-- HTN Meds and Adherence: ***
-- Other Med or Drug Use: ***
-- Symptoms: ***
-- Co-Morbidities: ***

Assessment:
-- History: *** h/o HTN, aortic disease, medications
-- Clinical: *** headaches, seizure, visual changes, dyspnea (edema), angina, tearing chest pain c/f dissection
-- Exam: *** BP on both arms, AMS, focal neuro deficit, papilledema, distress, diaphoresis, crackles
-- Data: *** CBC (Hgb), creatinine, UA (hematuria), troponin, CXR (flash edema), CT Head (stroke, PRES)
-- Etiology/DDx: *** nonadherence to home HTN meds, pain, anxiety, urinary retention, medications (NSAIDs, steroids), drugs (cocaine, amphetamines), pheo

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

Plan:
Workup
-- f/u CBC (MAHA), BMP (renal fx), BNP (CHF), trop (ACS), UA (glomerular injury)
-- f/u EKG, CXR (edema)
-- Consider UDS (drug-mediated), CT chest (dissection), CT head (focal deficits)
-- Consider secondary workup of hypertensive etiology - sleep study, renal artery doppler US, aldo:renin ratio >30, metanephrines, TSH
‍
Treatment
Urgency
-- goal to reduce BP to <160/100 over hours, then <130/90 over days; give short acting PO meds and discharge on long-acting PO meds
-- captopril, labetalol > hydralazine, isosorbide dinitrate
-- Dosages: Captopril 12.5-25mg q8h; Labetalol - PO 100mg q8-q12 (max 2400mg/d) or IV 10-80mg q10minutes → PO; Hydralazine - PO 10mg q6 or IV 5-20mg q15-30 minutes → PO; Isosorbide dinitrate - PO 5-20mg BID; Amlodipine - PO 2.5-5mg qday - increase 2.5mg q7d - takes few days for effect)
Emergency
-- goal to reduce no more than 25% in first hour (no lower than 160/100 within 2-5 hours, then to normotensive over 3-4 days
-- labetalol (10-80mg q10 min) > hydralazine (5-20mg q6); drips if transferred to the ICU
-- Dosages: Labetalol - dissection, CAD - 0.5-2mg/min to goal BP (max 10mg/min); Nitroprusside - CHF but not CAD - 0.25-2ug/kg/min to goal BP (max 10ug/kg/min); Nicardipine - SAH, dissection, renal failure - 5mg/hr up to 15mg/hr; Nitroglycerin - ACS, flash pulm edema - 10-30ug/min (max 400 ug/min)

Counseling: smoking cessation, weight loss, exercise, DASH diet, reduced salt intake, caffeine <2 cups daily, EtOH <2-3 drinks daily
‍
# Hypertensive Urgency/Emergency
Checklist
-- Gut Check: manual BP with correct sized cuff, check on both arms
-- ABCs: is there end-organ dysfunction suggesting emergency and need for ICU for a-line and close monitoring and titration of antihypertensives?
‍-- Chart Check: usual BP range, home BP meds, co-morbidities (CAD, CHF, CKD/ESRD)
-- Admission Criteria: evidence of end-organ dysfunction
-- HPI Intake: missed HTN meds, missed dialysis, drug use, pain, anxiety, headaches, visual changes, dyspnea, chest pain, oliguria
-- Can't Miss: red flags - dyspnea, chest pain, AMS, focal neuro symptoms
-- Admission Orders: CBC, CMP, UA, trop, BNP, EKG, CXR; consider tele, UDS, CTA Chest, CT head; restart home HTN regimen if applicable
-- Initial Treatment to Consider: IV vs. PO medications - usually labetalol unless ACS, CHF

Intake
-- HTN Meds and Adherence: ***
-- Other Med or Drug Use: ***
-- Symptoms: ***
-- Co-Morbidities: ***

Assessment:
-- History: *** h/o HTN, aortic disease, medications
-- Clinical: *** headaches, seizure, visual changes, dyspnea (edema), angina, tearing chest pain c/f dissection
-- Exam: *** BP on both arms, AMS, focal neuro deficit, papilledema, distress, diaphoresis, crackles
-- Data: *** CBC (Hgb), creatinine, UA (hematuria), troponin, CXR (flash edema), CT Head (stroke, PRES)
-- Etiology/DDx: *** nonadherence to home HTN meds, pain, anxiety, urinary retention, medications (NSAIDs, steroids), drugs (cocaine, amphetamines), pheo

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

Plan:
Workup
-- f/u CBC (MAHA), BMP (renal fx), BNP (CHF), trop (ACS), UA (glomerular injury)
-- f/u EKG, CXR (edema)
-- Consider UDS (drug-mediated), CT chest (dissection), CT head (focal deficits)
-- Consider secondary workup of hypertensive etiology - sleep study, renal artery doppler US, aldo:renin ratio >30, metanephrines, TSH

Treatment
Urgency
-- goal to reduce BP to <160/100 over hours, then <130/90 over days; give short acting PO meds and discharge on long-acting PO meds
-- captopril, labetalol > hydralazine, isosorbide dinitrate
-- Dosages: Captopril 12.5-25mg q8h; Labetalol - PO 100mg q8-q12 (max 2400mg/d) or IV 10-80mg q10minutes → PO; Hydralazine - PO 10mg q6 or IV 5-20mg q15-30 minutes → PO; Isosorbide dinitrate - PO 5-20mg BID; Amlodipine - PO 2.5-5mg qday - increase 2.5mg q7d - takes few days for effect)
Emergency
-- goal to reduce no more than 25% in first hour (no lower than 160/100 within 2-5 hours, then to normotensive over 3-4 days
-- labetalol (10-80mg q10 min) > hydralazine (5-20mg q6); drips if transferred to the ICU
-- Dosages: Labetalol - dissection, CAD - 0.5-2mg/min to goal BP (max 10mg/min); Nitroprusside - CHF but not CAD - 0.25-2ug/kg/min to goal BP (max 10ug/kg/min); Nicardipine - SAH, dissection, renal failure - 5mg/hr up to 15mg/hr; Nitroglycerin - ACS, flash pulm edema - 10-30ug/min (max 400 ug/min)

Counseling: smoking cessation, weight loss, exercise, DASH diet, reduced salt intake, caffeine <2 cups daily, EtOH <2-3 drinks daily

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