1-htn with end organ damage(emergency htn 180/120mmhg) :
ask about SOB , chest pain , palpitation , consciousness level (semi-unconscious , vomiting ,headache ,focal deficit , fit ) , blurred vision , leg edema ,oliguria ,confusion
اسأل المريض حول الاعراض التاليه
ضيق النفس\الم الصدر\خفقان\وعي غير تام او مضطرب \تقيئ\صداع\صرع\خلل عصبي في احد مناطق الجسم\غواش العين\الوذمه القدميه\قلة الادرار\
وجود اي عرض من هذه الاعراض يعني ان المريض في حالة
emergency htn not urgency htn
chest pain -sob : send ECG and troponin , check chest for pulmonary edema(heart failure), chest x ray
ddx: acute coronary syndrome , aortic dissection
DLOC-vomiting-severe headache-focal deficit-fit: send urgent CT scan
if ct was normal , suspect hypertensive encephalopathy
if there blurred vision (retinal injury) send to ophthalmologist
leg edema-oligurea-confusion-vomiting- send for renal function(Urea/Creatinine) suspect acute kidney injury
ddx : eclampsia (if pregnant ,also GUE for protein), acute renal failure
Management :htn emergency best managed with parenteral drugs
Na nitroprusside the most reliable antihypertensive agent ,its action begins immediately after administration and ends when the infusion is stopped (used in caution with impaired cerebral flow)
iv nitroglycerin best choice for pt prone to myocardial ischemia(avoided in pt with increased intracranial pressure)
esmolol effective in controlling htn with svt with severe htn (avoided in pt with low cardiac output because its negative inotropic effect (cardioselective beta adrenegic blocker)
for pulmonary edema we give furosemide(lasix iv) and angesid(nitroglycerine)
if ACS beta blocker plus ACS protocol(aspirin,clopidogrel,o2,sublingual nitrate,analgesia+etc)
if suspect aortic dissection: give labetalol iv , other neurological htn also use labetalol iv
hydralazine best management for preeclampsia and eclampsia
2-htn without end organ damage(urgency htn 180/120mmhg):
in this state , rapidly dropping blood pressure will affect brains perfusion , so tell the pt that there is danger of ؤerebral ischemia if we reduce blood pressure >25% during 24hr , urgency htn can managed by oral agent like
*captopril
* nifedipine
*prazosin
*clonidine
*labetalol
*nimodipine
all these agents shown to be effective in this situation
emergency management is captopril (capoten) tab 25mg and send them to outpatient specialist or consultant doctor
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management of hypertension in myocardial infarction patient :
if patient have mi and blood pressure was 210/120 mmhg
first , lower blood pressure to 160/100 in first hr
by nitroglycerine tab sublingual 3times (with 5 min interval between them )
if no response , iv nitroglycerin
angeside amp 10mg/10ml +500NS = 25drop /min
if no response
metoprolol tartrate 1amp (5mg/5ml) direct iv over 3min (max dose 15mg)
or labetalol 1amp (20mg/4ml) over 2min
*don't give anticoagulant - antiplatelet unless blood pressure below 180/100mmhg
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as a rule in hypertension :
if age <55 or have DM
start with ACEI(A) , then ACEI+ca(B) channel blocker , then add to them diuretic(D)
if all these three agents with no satisfying response , this called resistant hypertension
so consider further diuretic or alpha or beta blocker
>55 same but start with ca channel blocker (B) then A+B then A+B+D then if resistant hypertension consider another diuretic or alpha or beta blocker
agents for management of hypertensive urgency :
1- captopril ACEI , onset of action 5-15min , duration of action 2-6hr , dosing recommended 25mg po or SL , dosing range 6.25-50mg po , max dose 50mg po , adverse effect : hyperkalemia , angioedema , rash , decreased renal function in renal artery stenosis
2-clonidine : centrally acting a2 agonist , onset 15-30min,duration of action 2-8hr , recommended dose 0.1-0.2mg po , followed by 0.05-0.1mg every hour until desired effect , max dose 0.8mg , adverse effect : dry mouth , sedation , orthostatic hypotension , rebound hypertension
3-labetalol , a1 selective , beta non selective antagonist , onset 2h , duration 4h , recommended dose 200mg/po followed by 200mg every hour until desired effect , max dose 1.2g, side effect : hypotension , dizziness , headache , nausea , vomiting
