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Management of hypertensive urgencies & emergencies

Management of hypertensive urgencies & emergencies. Emergencies: BP> 180/120 – impending/ progressive target organ damage Immediate reductions required. Urgencies: severe elevations in BP without progressive target organ damage

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Management of hypertensive urgencies & emergencies

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  1. Management of hypertensive urgencies & emergencies

  2. Emergencies: • BP> 180/120 – impending/ progressive target organ damage • Immediate reductions required. • Urgencies: • severe elevations in BP without progressive target organ damage • - Severe headache, shortness of breath, epistaxis, severe anxiety

  3. Emergencies:-decrease mean BP by 25%(within minutes to one hour) • If stable  to 160/100-110mmHg – next 2 – 6 hrs. • Excessive fall!!! • If stable – normal BP – 24 – 48 hrs • EXCEPTIONS: Patients with ischemic stroke • - Aortic dissection (↓SBP to <100 mmHg) • - Patients in whom BP is lowered to enable use of thrombolytic agents

  4. Oral agents: captopril, labetalol, clonidine Complications of aggressive management!

  5. Treatment of acute severe hypertension in preeclampsia Hydralazine ■ 5 mg iv bolus, then 10 mg every 20–30 minutes to a maximum of 25 mg, repeat in several hours as necessary Labetalol (second-line) ■ 20 mg iv bolus, then 40 mg 10 minutes later, 80 mg every 10minutes for two additional doses to a maximum of 220 mg Sodium nitroprusside (rarely, when others fail) ■ 0.25 μg/kg/min to a maximum of 5 μg/kg/min ■ Fetal cyanide poisoning may occur if used for more than 4 hours

  6. Treatment of acute severe hypertension in preeclampsia Nifedipine (controversial) ■ 10 mg po, repeat every 20 minutes to a maximum of 30 mg ■ Caution when using nifedipine with magnesium sulfate, can see precipitous blood pressure drop ■ Short-acting nifedipine is not approved by the Food and Drug Administration for managing hypertension

  7. DrugSodium nitroprusside Dose 0.25–10 μg/kg/min as IV infusion Onset of ActionImmediate Duration of Action1–2 min Adverse Effects:Nausea, vomiting, muscle twitching, sweating, thiocynate and cyanide intoxication Special Indications:Most hypertensive emergencies; caution with high intracranial pressure or azotemia

  8. Drug: Nicardipine hydrochloride Dose:5–15 mg/h IV Onset of Action:5–10 min Duration of Action:15-30 min, may exceed 4 hrs Adverse Effects:Tachycardia, headache, flushing, local phlebitis Special Indications:Most hypertensive emergencies except acute heart failure; caution with coronary ischemia

  9. Drug:Fenoldopam mesylate Dose: 0.1–0.3 μg/kg per min IV infusion Onset of Action:<5 min Duration of Action:30 min Adverse Effects:Tachycardia, headache, nausea, flushing Special Indications:Most hypertensive emergencies; caution with glaucoma

  10. Drug:Nitroglycerin Dose: 5–100 μg/minas IV infusion Onset of Action:2–5 min Duration of Action:5–10 min Adverse Effects:Headache, vomiting,methemoglobinemia,tolerance with prolonged use Special Indications: Coronary ischemia

  11. Drug:Enalaprilat Dose: 1.25–5 mg every6 hrs IV Onset of Action:15–30 min Duration of Action:6–12 hrs Adverse Effects:Precipitous fall in pressurein high-renin states; variable response Special Indications:Acute left ventricular failure; avoid in acute myocardial infarction

  12. Drug: Hydralazine hydrochloride Dose:10–20 mg IV 10–40 mg IM Onset of Action:10–20 min IV20–30 min IM Duration of Action:1–4 hrs IV 4–6 hrs IM Adverse Effects:Tachycardia, flushing, headache,vomiting,aggravation of angina Special Indications:Eclampsia

  13. Drug: Labetalol hydrochloride Dose:20–80 mg IVbolus every 10 min 0.5–2.0 mg/min IV infusion Onset of Action:5–10 min Duration of Action:3–6 hrs Adverse Effects:Vomiting, scalp tingling,bronchoconstriction, dizziness, nausea,heart block, orthostatic hypotension Special Indications:Most hypertensive emergencies except acute heart failure

  14. Drug:Esmolol hydrochloride Dose:250–500 μg/kg/minIV bolus, then 50–100 μg/kg/min by infusion; may repeat bolus after 5 min or increase infusion to300 μg/min Onset of Action:1–2 min Duration of Action:10–30 min Adverse Effects:Hypotension, nausea, asthma,first degree heart block,heart failure Special Indications:Aortic dissection, perioperative

  15. Drug:Phentolamine Dose:5–15 mg IV bolus Onset of Action:1–2 min Duration of Action:10–30 min Adverse Effects:Tachycardia, flushing, headache Special Indications:Catecholamine excess

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