Optimal Management of Hypertensive Emergency Patients: Clinical Scenarios & Panel Discussion

1. Optimal Management of Hypertensive Emergency Patients:Clinical Scenarios &Panel Discussion

2. EMRA Resident Forumat Scientific Assembly 2010 Las Vegas, NV September 2008, 2010

3. www.ferne.org

4. Edward P. Sloan, MD, MPH FACEPProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL

5. Attending PhysicianEmergency MedicineUniversity of Illinois HospitalSwedish American Belvidere HospitalChicago, IL

6. Panelists E Bradshaw Bunney, MD: Emergency Medicine Residency Director Associate Professor University of Illinois Department of Emergency Medicine Heather Prendergast MD, MPH: Associate Professor University of Illinois Department of Emergency Medicine Daniel G. Murphy, MD, MBA: Emergency Medicine Director, Mercy Medical Center Long Island, NY

7. Panelists Andy Jagoda, MD: Professor and Chair Mt Sinai Department of Emergency Medicine, NY Richard Shih, MD: Emergency Medicine Residency Director Residency Program Director Department of Emergency Medicine Morristown Memorial Hospital New Jersey Medical School

8. Disclosures • FERNE Chairman and President • FERNE advisory board for The Medicine Company in May 2007 • FERNE grant by The Medicines Company to support this program • No individual financial disclosures

9. Disclosures • Jagoda: FERNE The Medicines Company in 2007 • Bunney: FERNE, Genentech 2010 • Murphy: None • Prendergast: FERNE • Shih: None • No other individual financial disclosures

10. Thank You • EMRA • EMRA staff • EB Medicine • The Medicines Company • FERNE staff • Panelists • All of you

11. Hypertensive Crisis • Hypertensive urgency: • elevation of blood pressure without acute end organ damage • Hypertensive emergency • elevation of blood pressure with acute end organ damage • Diastolic BP usually >120 in both instances

12. Q: Who/what do you treat? Do you treat the pt or the number? 1. Patient 2. Number 3. Patient, but if pressed, I will treat the number regardless

13. Q: What number do you treat? Do you treat SBP, DBP, or MAP? 1. SBP 2. DBP 3. MAP

14. Q: Mean Arterial Pressure Do you know how to calculate MAP? 1. Yes 2. No

15. Q: Mean Arterial Pressure 1/3 systolic + 2/3 diastolic 180/120 = 60 + 80 = 140 MAP 120/90 = 40 + 60 = 100 MAP

16. Q: Diastolic BP Above what diastolic BP will you treat a patient, regardless if the pt is asymptomatic and the BP elevation in chronic? 1. 100 2. 110 3. 120 4. 130 5. 140

17. Q: Treatment Endpoint What is your successful treatment endpoint? 1. Absolute drop in endpoint BP 2. % Drop in endpoint BP 3. Depends on how high BP is 4. Depends on clinical situation 5. Varies, not consistent

18. Case 1: Ischemic Stroke A 64 year old male patient with a history of hypertension and diabetes presents to the Emergency Department with a new onset of ipsilateral right-sided facial droop, arm and leg weakness, aphasia, and gaze to the left. His vital signs are BP 230/135, HR110, RR 16, and Temp 98.4.

20. Case 2: AMS/Coma A 49 year old male patient with a history of hypertension presents to the Emergency Department with a thunderclap headache, vomiting, and altered mental status. Upon arrival to the ED, he becomes unresponsive. His vital signs are BP 264/142, HR 90, RR 12, and Temp 98.4.

22. Q: How would you Rx these pts? What type of anti-hypertensive agent would you use? 1. Oral 2. IV bolus 3. Continuous infusion 4. Other

23. Q: What IV anti-hypertensive? What IV bolus agent might you use? 1. Hydralazine 2. Labetalol 3. Enalaprilat 4. Phentolamine 5. Other

24. Q: What IV anti-hypertensive? What IV infusion Rx might you use? 1. Sodium nitroprusside 2. Nicardipine 3. Fenoldopam 4. NTG 5. Esmolol 6. Clevidipine

25. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? How? Why?

26. Q: Does Rx Differ ICH vs. Ischemic Stroke? Does BP management differ in ICH patients as compared to ischemic stroke patients? How? Why?

27. Case 3: Chest Pain A 68 year old male presents with chest pain, sub-sternal described as severe. Onset less than one hour prior to arrival. Associated with nausea, diaphoresis. No known cardiac history . Patient is a Smoker, ?cholesterol. His vital signs are BP 198/118, HR100, RR 20, and Temp 98.8.

29. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? 1. Oral 2. IV bolus 3. Continuous infusion 4. Other

30. Q: What IV anti-hypertensive? What IV bolus agent might you use? 1. Hydralazine 2. Labetalol 3. Enalaprilat 4. Phentolamine 5. Other

31. Q: What IV anti-hypertensive? What IV infusion Rx might you use? 1. Sodium nitroprusside 2. Nicardipine 3. Fenoldopam 4. NTG 5. Esmolol 6. Clevidipine

32. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? How? Why?

33. Case 4: Dyspnea, ESRD A 58 year old female patient with a history of ESRD on dialysis , hypertension, pacemaker and diabetes brought to the Emergency Department by EMS for vomiting and mild frontal headache. Per family, pt missed her last dialysis session. Her vital signs are BP 225/142, HR125, RR 30, and Temp 98.4.

35. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? 1. Oral 2. IV bolus 3. Continuous infusion 4. Other

36. Q: What IV anti-hypertensive? What IV bolus agent might you use? 1. Hydralazine 2. Labetalol 3. Enalaprilat 4. Phentolamine 5. Other

37. Q: What IV anti-hypertensive? What IV infusion Rx might you use? 1. Sodium nitroprusside 2. Nicardipine 3. Fenoldopam 4. NTG 5. Esmolol 6. Clevidipine

38. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? How? Why?

39. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? 1. Oral 2. IV bolus 3. Continuous infusion 4. Other

40. Q: What IV anti-hypertensive? What IV bolus agent might you use? 1. Hydralazine 2. Labetalol 3. Enalaprilat 4. Phentolamine 5. Other

41. Q: What IV anti-hypertensive? What IV infusion Rx might you use? 1. Sodium nitroprusside 2. Nicardipine 3. Fenoldopam 4. NTG 5. Esmolol 6. Clevidipine

42. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? How? Why?

43. Case 5: Ankle Sprain A 44 year old male patient with no significant past medical history presents to the Emergency Department with acute ankle injury while getting off the bus. Exam shows significant soft tissue swelling to lateral malleolus. His vital signs are BP 197/126, HR 89, RR 16, and Temp 98.4.

45. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? 1. Oral 2. IV bolus 3. Continuous infusion 4. Other

46. Q: What IV anti-hypertensive? What IV bolus agent might you use? 1. Hydralazine 2. Labetalol 3. Enalaprilat 4. Phentolamine 5. Other

47. Q: What IV anti-hypertensive? What IV infusion Rx might you use? 1. Sodium nitroprusside 2. Nicardipine 3. Fenoldopam 4. NTG 5. Esmolol 6. Clevidipine

48. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? How? Why?

49. Q: Outpatient HTN Rx Would you start them on an anti-hypertensive medication? 1. Yes 2. No

50. Q: Disposition What special instruction would you give for follow-up? Where? When?