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Hypertension - hospital

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Thomas Marcus

on 10 March 2015

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Transcript of Hypertension - hospital

Hypertensive crisis


Thomas Marcus

Case Example

Mrs S is a 60 y/o lady who was bought in to ED with polypharmacy overdose - regular benzodiazepam and morphine. After 4 days in ICU she was transferred to the ward for ongoing management

Past Medical History
Hypertension
IHD
Obesity
Chronic abdominal pain
known to chronic pain team
multiple investigations and procedures
on 80mg morphine / day
Stroke
AKI

Day 1 post ICU
- suspected SBO – required CT abdomen to rule out.
-Cr - 248

Day 2
- very difficult to cannulate – failed anaesthetic attempts, unable to have blood taken

Day 3
-Paracetamol, small doses of endone and fentanyl – due to poor renal function
- uncontrolled abdominal pain – hyper tensive 200< systolic overnight received amlodipine 10mg

Day 4
- unable to get bloods
- on regular calcium channel blocker
- poor pain control
- continuing >200 SBP despite further anti hypertensive treatment
- NO symptoms of end organ damage


Day 4 - continued

- systolic 200< - new neurological symtpoms
- stroke call – large haemorrahagic stroke – transported to Melbourne.


Hypertension

Pager: pt BC 6 178/90 needs R/V

Or

“just letting you know that this patient is 180 / 100

Causes

MANY

Life threatening
- Aortic dissection
- Myocardial infarction
- Acute pulmonary oedema
- Subarachnoid haemorrhage
- Preeclampsia/eclampsia
- Hypertensive encephalopathy
- Acute renal failure

Benign...

- Missed hypertensive medications
- Anxiety or stress
- Urinary retention / constipation
- Pain

Classification

Hypertensive crisis – systolic BP >179 or diastolic >109

Hypertensive urgency – Without evidence of acute end organ damage -
Lowered over 1-2 days – due to deceasing too fast put patients at risk of myocardial or cardiac ischemia due to hypo perfusion
Target <160/100mmHg no more then 25% of MAP in several hours


Hypertensive emergency - Evidence of end organ damage
Blood pressure to be lowered over hours.

However there is no threshold for end organ damage and can occur at lower pressures.

Non pharmacological treatments

- treating underlying cause - eg pain, retention
- move to quiet room - environment

Pharmacological treatments

48 hours
Patients already on hypertensives
- check if had regular dose
- consider increasing regular dose
- add additional antihypertensive

Untreated hypertension
- Angiotensin converting enzyme (ACE) Inhibitor
o Ramipril 1.25 – max 10mg daily
o Perindopril 2.5mg max 10mg daily
- Angiotensin receptor blocker (ARB)
o Candesartan 4mg
- Calcium channel blocker – peripheral oedema
o Amlodipine 5mg max 10mg daily
o Lericanidipine 10mg daily
- Beta blocker - asthma
o Metoprolol 12.5mg – 50mg BD

There is no evidence that one class is better then another. Choice of person prescribing, often duel classes used.
Fast Hours: -
IV labetalol
IV GTN
IV Sodium nitroprusside
Hydralazine

Renal impaired

WH – unknown reason why???

Avoid – ACE and ARBs as increase in potassium levels
Alpha/beta blockers – renal excreted
Furosemide is ok to use – be careful of concurrent use with NSAIDs or hypovolemic patient

Stroke patients

AVOID reducing blood pressure quickly, puts at higher risk of hypo perfusion

Approach.......

History and examination

Take the blood pressure yourself……

Classification

- Hypertensive crisis >180 systolic or >100 diastolic

-
Urgency
vs
emergency

Presents of end organ damage

Raised ICP/encephalopathy - Headache, blurry vision, nausea vomiting
,confusion

Chest pain – myocardial infarction, aortic dissection

Shortness of breath – pulmonary oedema

Focal neurology – stroke

Haematuria

Cause

Most common

Essential
Pain
Stress/anxiety
Retention/constipation
Not taking regular anti hypertensive medications

Secondary
- Renal disease

- Endocrine disease

- Medications

- Neurogenic

Many more

Treatments

Treat the cause – pain, retention, anxiety etc

1.Ca channel blockers
-amlodipine 5 + 5 mg if needed

- Lercanidipine 10 + 10mg, if worried about peripheral overload.

2.GTN patch 5mg – 25mg
- take off when SBP<140
- 12 hours on/off

3.Frusemide
Overload – 20mg IV or 40 mg orally

THANK YOU

Questions?
References
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2009.06228.x/pdf

www.uptodate.com

www.australianprescriber.com.au

On call

Intershipcommon clinical cases

Barwon Health registrars

Full transcript