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
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