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Hypertensive Emergency (Common Cross-Cover Calls)

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An overview of how to approach calls regarding elevated blood pressure while cross-covering on inpatient medicine. The distinction between hypertensive emergency and urgency is covered, as well as some of the differences between various anti-hypertensives appropriate when treating acute hypertension.

Hello everyone this video will review how to handle cross cover phone calls related to acute hypertension in the hospital the learning objectives of this video are to know the ideologies of acute hypertension in the hospitalized patient be able to distinguish a hypertensive emergency from a hypertensive urgency or even a simple uncomplicated high blood pressure

Reading and to know treatment options for acute lowering of blood pressure so let’s say you’re one of the on-call interns it’s 10 p.m. and you’re hanging out in the cafeteria getting some coffee in preparation for what you anticipate may be a long night then you hear this it’s ward 3c patient t williams just had a blood pressure checked of 190 over 110 with heart

Rate 110 mild headache please write for prn or eval which translates to please write for an as-needed antihypertensive or come to evaluate the patient at the bedside as with most cross cover problems the four step basic approach should be the first consider the ideologies of the basic problem as you walk over to the patient’s room to evaluate him or her once

At the bedside the most immediate question to answer is not what’s causing this but rather how severe do you think this is in other words is this something that will require transfer to another floor or to the icu and is this something for which you’ll need additional help in order to assess the severity of course you need to initiate some form of evaluation and

Finally you’ll need to order treatment if in fact treatment is even indicated so now you’re walking over to ward 3c to see ms williams what are the possible ideologies up or hypertension that you need to be worried about the list of ideologies of acute hypertension in the hospitalized patient is not the same as a list of ideologies of hypertension in general after

All you shouldn’t be worried about diagnosing hyperaldosteronism or korek tation of the aorta when your cross covering at night so let’s just consider those causes which have a reason to happen specifically in the hospital i’ll divide them into common and uncommon ideologies of acute hypertension based on my own personal experience the most common appears to be

Patients missing their outpatient antihypertensives two in particular which are known for causing rebound hypertension when abruptly discontinued are clonidine and beta blockers though holding any anti hypertensive in the hospital could result in higher blood pressures of course other ideologies include drug withdrawal such as that seen with alcohol and benzos

Anxiety and pain delirium volume overload while volume overload can occur in a wide variety of settings overload leading specifically to acute hypertension is seen especially in patients with chronic kidney disease and finally acute stroke now there are also some uncommon causes of acute hypertension in hospitalized patients while some residents may never encounter

A case of these during all of cross cover throughout residency if you never consider the diagnosis you’ll never make the diagnosis pheochromocytoma acute exacerbations which can be triggered by surgery or anesthesia malignant hyperthermia which is a very rare hypermetabolic crisis triggered by volatile anesthetics in susceptible individuals neuroleptic malignant

Syndrome serotonin syndrome autonomic dysreflexia seen almost solely in patients with high spinal cord injuries and last elevated intracranial pressure when it comes to assessing the severity of acute hypertension it’s dependent upon the presence and severity of symptoms as well as the presence and severity of the objective signs of acute end-organ dysfunction when

Severe hypertension is associated with secondary acute and organ dysfunction the situation is called hypertensive emerge agency and it is in fact an emergency when severe hypertension is not associated with acute and organ dysfunction this is historically called hypertensive urgency the cutoff of what is considered severe is arbitrary but most commonly quoted as a

Systolic pressure of 180 or more or a diastolic pressure of 110 or more though the actual urgency of it depends greatly on the patient’s baseline pressure and other current comorbid conditions what are the symptoms and signs of acute and organ dysfunction attributable to hypertensive emergency that there is what specifically should you be looking for at the bedside

In order to conclude that an emergency is present these map pretty well into six categories in the heart we have chest pain elevated troponin and acute ischemic changes on ekg in the lungs you should ask about this nia listen for crackles or look for pulmonary edema on chest x-ray neurologic dysfunction can manifest as confusion focal neuro deficits or evidence

Of intracranial hemorrhage on head ct acute hypertension can lead to hematuria and acute kidney injury the eyes can get visual changes retinal hemorrhages and papilledema and finally vascular problems can include symptoms and signs of aortic dissection the presence of any of the above when combined with the systolic pressure above 180 or diastolic pressure above

110 should usually be classified as a hypertensive emergency much of the initial bedside evaluation has been implied with that last list first step recheck vitals including the blood pressure in both arms a large discrepancy is a very crude screen for aortic dissection also in the event of a large discrepancy you should generally treat based on the higher number

Consider the details of the patient sign out is he or she being treated for any condition related to a hypertensive emergency already or do they have a history of a medical problem that may respond particularly poorly to certain changes in blood pressure for example patients with severe mitral regurgitation can develop abrupt pulmonary edema in the setting of high

Blood pressure and patients with severe aortic stenosis can experience a much greater than anticipated drop and blood pressure in response to treatment with vasodilators perform a focused exam including but not limited to a thorough cardiovascular and pulmonary exam and a five-minute screening neural exam looking for evidence of intracranial hemorrhage large

Stroke or hypertensive encephalopathy you should also consider a retinal exam looking for retinal hemorrhages and papilledema i suggest that you should consider this instead of making it an essential part of the evaluation not because it is important but because of the surprisingly frequent difficulty in locating an ophthalmoscope in many us hospitals if you

Happen to have one available use it if not i would only spend time tracking one down if the patient was voicing a visual complaint next compare the outpatient and inpatient medalists looking for anything that the primary team may have forgotten to continue in the hospital related to that check to see if any inpatient antihypertensives were recently held for any

Reason for example it’s not unheard of for some antihypertensives to be inappropriately held due to mild bradycardia even meds that don’t cause bradycardia at therapeutic doses like the dihydropyridine class of calcium channel blockers review the patient’s substance abuse history and check out a mission urine tox screen to see if he or she could be withdrawing from

Something considered checking a basic metabolic panel and you a largely looking for evidence of acute kidney injury or hematuria as manifestations of hypertensive emergency though i don’t do this for most patients and finally consider checking an ekg for evidence of secondary myocardial ischemia the fourth and last step in our basic approach is to order treatment

If indicated the initial consideration in treatment is always to start by treating the underlying cause of a hypertension so for a patient with alcohol withdrawal give benzos for volume overload complicating chronic kidney disease this often responds well to diuretics obvious give analgesics to patients in pain and for patients who are hypertensive in the setting

Of delirium see my related video on handling altered mental status once you’ve considered treatment specific for the underlying cause you should also consider antihypertensive treatment in the more general sense regarding antihypertensive treatment there are three basic questions to answer first this is patient need acute treatment at all anyone with hypertensive

Emergency requires immediate intravenous antibiotics and icu or near icu level care in general there is no immediate need to treat hypertension outside of a hypertensive emergency with some exceptions such as patients receiving active treatment for acs heart failure and neurologic emergencies just because someone alerts you to the presence of hypertension does

Not mean you are obligated to order treatment the second question to answer about anti hypertensive treatment is what should be the target blood pressure the target varies dramatically depending upon the severity of the patient’s symptoms and signs the starting blood pressure and the patient’s typical baseline blood pressure going back to our patient for whom we

Were paged with a pressure of 190 over 110 our approach to her would be very different and for baseline blood pressure was 180 over 100 then if it were 110 over 70 and as a general rule lower pressure by no more than 20 to 25 percent in the first several hours unless of course the signs and symptoms of acute end organ dysfunction are still present and continuing

In which case lower pressure may be necessary in the event that a patient is experiencing a hypertensive emergency which would normally require lowering a blood pressure simultaneous with an acute ischemic stroke for which a permissive hypertension is usually advised an appropriate blood pressure goal is very tricky and then possible to generalize about if you are

Faced with the specific circumstance and do not have prior experience with it strongly consider seeking more senior guidance the final question to answer is what are the specific options for treatment of a hypertension i’ve divided the treatment options into two charts those most appropriate for hypertensive emergencies and those for hypertensive urgency meds for

Hypertensive emergencies include nitroprusside nitroglycerin labetalol asthma law and my card open each is available as a continuous iv infusion and each has its advantages leading to particular indications as well as disadvantages leading to particular contraindications in the interest of time i won’t review the whole list but consider pausing the video here if you

Like the only things remotely specific that i’ll say about the madness chart concerns nitroprusside nitroprusside is a wonderfully effective medication as it dilates both arteries and veins to near equal amounts and can be very rapidly titrated thus it can be used for just about any form of hypertensive emergency however it’s also one of the most problematic due to

The fact that the drug releases cyanide during its metabolism which can potentially lead to clinical deterioration and death so it’s both the most effective drug and the one requiring the closest monitoring which is why it’s the only drug on this list that i would never use outside of an icu this chart is for those meds which are more appropriate for hypertensive

Urgency the first three hydralazine labetalol and metoprolol are all available as both an iv bolus and the pio these are the three most common go-to drugs for acute treatment of moderate hypertension outside of an icu the indications and contraindications are relatively straightforward the last three meds oral clonidine oral or sublingual captopril and sublingual

Nitroglycerin are essentially the options to use to quickly bring down a patient’s blood pressure without needing iv access as you can see the advantage to these meds are they’re relatively quick onset while the disadvantage is they’re less predictable effect one of the only circumstances where i would consider any of these three meds would be either a severely

Hypertensive but a symptomatic patient in clinic in whom you’re trying to avoid admitting to the hospital and would like to buy time for a newly prescribed and more conventional antihypertensive to start working another circumstance for these meds are patients with severe hypertension on an inpatient psychiatry ward who would fare poorly being transferred either to

The er or inpatient medicine due to uncompensated psychiatric disease i’ll end with this algorithm which will hopefully help you decide on an appropriate medication during a hypertensive crisis first ask if the patient has symptoms or signs of acute end organ dysfunction if yes that as you now know the patient is having a hypertensive emergency and requires immediate

Iv meds if he or she is critically ill in general consider nitroprusside if angela is the presenting problem consider nitroglycerin or beta blocker if pulmonary edema is the problem consider nitroglycerin furosemide could also be used here as an adjunctive agent in a neurologic emergency consider an eye card open if the patient is not having a hypertensive emergency

Ask whether the patient is being actively treated for acute coronary syndrome heart failure or intracranial hemorrhage well that sounds like qualifications for emergency the somewhat irrelevant distinction is whether the hypertension came after the other medical problem or the other medical problem was triggered by the hypertension the reason why this distinction

Is more or less irrelevant at least irrelevant in the immediate sense is because these patients should essentially be treated as if they were having a hypertensive emergency regardless if none of these problems are present ask if the current blood pressure is substantially higher than the patient’s baseline if it is you could consider treatment with iv labetalol

Metoprolol or hydralazine if the current pressure isn’t substantially different from baseline no immediate treatment is necessary review the outpatient medalists for meds that are mistakenly missing from the inpatient orders recheck the pressure in two to four hours and you can usually defer further treatment decisions to the primary in the morning if the pressure

Remains unchanged or is improved at that recheck so there’s the overview of the treatment of acute hypertension while on inpatient cross cover please feel free to leave any comments or questions you

Transcribed from video
Hypertensive Emergency (Common Cross-Cover Calls) By Strong Medicine