Hypertensive Crisis with Dr. Travis Huffman

Summary

In this Little Lecture, Travis Huffman, a second-year internal medicine resident at the University of Louisville, discusses hypertensive crises. He differentiates between markedly elevated blood pressure and hypertensive crisis, emphasizing the importance of identifying target organ damage. The lecture guides through clinical signs to assess, diagnostic tests, and treatment algorithms, including the use of IV antihypertensives for hypertensive emergencies. Special considerations for conditions like aortic dissection, strokes, and preeclampsia in pregnancy are highlighted, stressing the need for tailored treatment approaches.

Takeaways

• 📚 The lecture discusses hypertensive crises, distinguishing between 'markedly elevated blood pressure' and 'hypertensive crisis'.
• 🌡️ A blood pressure reading of systolic greater than 180 mmHg and diastolic greater than 120 mmHg is considered severely elevated.
• 🔍 Clinical assessment should focus on identifying target organ damage, such as headaches, visual changes, chest pain, or changes in mental status.
• 🩺 Diagnostic workup may include CBC, CMP, troponin, urinalysis, and imaging studies like CT head or chest X-ray to evaluate for organ damage.
• 🏥 Patients with hypertensive crisis and end-organ damage should be admitted to the ICU for continuous blood pressure monitoring and treatment with IV antihypertensives.
• 💊 The treatment algorithm for hypertensive crisis involves a gradual reduction in blood pressure to avoid hypoperfusion, aiming for a 25% decrease in the first hour.
• 🚫 There are four clinical scenarios that alter the treatment approach: acute aortic dissection, ischemic and hemorrhagic strokes, preeclampsia/eclampsia, and pheochromocytoma.
• 🤰 In pregnant patients with hypertensive crisis, safe medications include hydralazine, methyldopa, labetalol, and nifedipine.
• 🧬 For patients with pheochromocytoma, alpha blockade is initiated before beta blockade, aiming to reduce blood pressure to less than 140 systolic in the first hour.
• 🔄 The lecture emphasizes the importance of recognizing and adjusting treatment based on the presence of end-organ damage and specific clinical scenarios.

Q & A

What is the main topic of the Little Lectures presented by Travis Huffman?

The main topic is hypertensive crises, focusing on the differentiation between markedly elevated blood pressure and hypertensive crisis.

What are the blood pressure thresholds that define a hypertensive crisis according to the lecture?

A hypertensive crisis is defined by a systolic blood pressure greater than 180 millimeters of mercury (mmHg) and a diastolic blood pressure greater than 120 mmHg.

What is the difference between hypertensive urgency and hypertensive emergency as discussed in the lecture?

The terms hypertensive urgency and hypertensive emergency are used interchangeably with markedly elevated blood pressure and hypertensive crisis, respectively, in the lecture. The key difference is the presence of end-organ damage, which indicates a hypertensive crisis.

What are the clinical signs and symptoms that suggest possible end-organ damage in a patient with hypertensive crisis?

Signs and symptoms that suggest end-organ damage include headaches, visual changes, changes in mental status, chest pain, shortness of breath, abdominal pain or vomiting, and changes in urine color or output.

What diagnostic tests are recommended for a patient presenting with hypertensive crisis?

Diagnostic tests recommended include a CBC, CMP, troponin, UA, and imaging studies such as CT head, chest x-ray, and possibly CTA or MRA for suspected aortic dissection.

How should blood pressure be managed in a patient with hypertensive crisis in the ICU setting?

In the ICU, blood pressure should be managed with IV antihypertensives, continuous blood pressure monitoring through an arterial line, and following an algorithm that aims to reduce blood pressure by no more than 25% in the first hour.

What are the four clinical scenarios where the treatment algorithm for hypertensive crisis needs to be altered?

The four clinical scenarios are acute aortic dissection, ischemic and hemorrhagic strokes, pheochromocytoma, and preeclampsia/eclampsia in pregnant patients.

What is the recommended blood pressure goal for a patient with an acute aortic dissection?

For acute aortic dissection, the goal is to acutely drop the systolic blood pressure to less than 120 mmHg within the first 20 to 40 minutes, or at least less than 140 mmHg in the first hour.

How should blood pressure be managed in pregnant patients with preeclampsia or eclampsia?

In pregnant patients with preeclampsia or eclampsia, the goal is to reduce systolic blood pressure to less than 140 mmHg in the first hour using medications safe for pregnancy such as hydralazine, methyldopa, labetalol, and nifedipine.

What is the recommended approach for managing hypertensive patients in the outpatient setting who are asymptomatic and compliant with treatment?

For asymptomatic outpatients who are compliant, the approach is to intensify their medication regimen. For non-compliant patients, it's advised to give them their home medications to avoid the risk of hypotension from additional medications.

Outlines

00:00

🩺 Hypertensive Crises: Definitions and Diagnostic Approach

This segment of the lecture focuses on hypertensive crises, distinguishing between 'markedly elevated blood pressure' and 'hypertensive crisis' as per the ACC/AHA guidelines. The speaker, Travis Huffman, a second-year internal medicine resident, explains that markedly elevated blood pressure is characterized by systolic blood pressure over 180 mmHg and diastolic over 120 mmHg. The lecture emphasizes the importance of investigating for target organ damage when such blood pressure readings are encountered. Clinical signs and symptoms to assess include headaches, visual changes, altered mental status, chest pain, shortness of breath, and changes in urine output or color. Diagnostic workup may involve CBC, CMP, troponin, urinalysis, and imaging studies like CT scans or MRI for suspected stroke, and chest X-rays or CTAs for aortic dissection. The lecture also touches on the management of hypertensive urgency and emergency in the inpatient setting, including the use of IV antihypertensives and the importance of continuous blood pressure monitoring.

05:00

💡 Management Strategies for Hypertensive Crises

The second paragraph delves into the management strategies for hypertensive crises, particularly in the inpatient setting. It discusses the use of IV medications such as calcium channel blockers, beta blockers, vasodilators, and nitroglycerine to acutely lower blood pressure. The speaker outlines an algorithm for treatment that involves an initial drop in blood pressure by no more than 25% in the first hour, followed by a further reduction to less than 160/110 within two to six hours, and finally normalizing blood pressure over 24 to 48 hours. The lecture also addresses special clinical scenarios that require deviation from the standard algorithm, including ischemic and hemorrhagic strokes, aortic dissection, preeclampsia/eclampsia in pregnant patients, and pheochromocytoma. For each of these scenarios, specific treatment goals and medications are recommended. The speaker concludes with three key takeaway points: understanding the definitions of severely elevated hypertension, identifying end-organ damage, and recognizing clinical situations that require altered treatment approaches.

Keywords

💡Hypertensive crises

Hypertensive crises refer to a medical emergency characterized by severely elevated blood pressure, typically with systolic pressure greater than 180 mm Hg and diastolic pressure greater than 120 mm Hg. In the script, this term is central as it sets the stage for discussing the urgency and potential dangers of such high blood pressure levels, which can lead to organ damage if not managed properly.

💡Markedly elevated blood pressure

This term is used interchangeably with 'hypertensive crises' in the script to describe blood pressure readings that are significantly higher than normal, indicating a potential medical emergency. It is important for healthcare providers to recognize these readings as they may signal hypertensive crises and require immediate attention.

💡Hypertensive emergency

A hypertensive emergency is a subset of hypertensive crises where there is evidence of acute end-organ damage, such as encephalopathy, acute myocardial infarction, pulmonary edema, or eclampsia. The script emphasizes the need for rapid blood pressure reduction in these cases to prevent further damage to the affected organs.

💡End-organ damage

End-organ damage refers to harm to vital organs such as the brain, heart, or kidneys due to high blood pressure. The script discusses the importance of assessing for signs of such damage, as it dictates the urgency and approach to treatment. For instance, if a patient presents with symptoms like headache, visual changes, or chest pain, these could indicate end-organ damage requiring immediate intervention.

💡Intracranial pressure

Intracranial pressure is the pressure within the skull, and it can increase due to conditions like brain tumors or hemorrhages. In the context of the script, symptoms like headaches, visual changes, or altered mental status may suggest increased intracranial pressure, which is a critical factor to consider in the management of hypertensive crises.

💡Aortic dissection

An aortic dissection is a life-threatening condition where the inner layer of the aorta tears, allowing blood to flow between the layers of the aortic wall. The script mentions this as a critical condition that can be exacerbated by high blood pressure, necessitating aggressive treatment to lower blood pressure and stabilize the patient.

💡Pulmonary edema

Pulmonary edema is a condition where fluid accumulates in the lungs, often as a result of heart failure. The script discusses it as a potential complication of hypertensive crises, where high blood pressure can lead to fluid leakage into the lungs, causing shortness of breath and respiratory distress.

💡Preeclampsia/Eclampsia

Preeclampsia is a pregnancy complication characterized by high blood pressure and damage to organs such as the liver and kidneys. Eclampsia is a severe form of preeclampsia that includes seizures. The script highlights the importance of recognizing these conditions in pregnant patients and managing blood pressure with medications that are safe for both mother and fetus.

💡Pheochromocytoma

Pheochromocytoma is a rare tumor that originates from the adrenal medulla and can cause intermittent severe hypertension. The script mentions it as a condition that requires specific treatment protocols, including alpha and beta blockade, to manage blood pressure spikes effectively.

💡IV antihypertensives

IV antihypertensives are intravenous medications used to rapidly lower blood pressure in hypertensive emergencies. The script discusses the use of these medications, such as labetalol, nitroprusside, and hydralazine, in a controlled setting like an ICU to manage severe hypertension and prevent organ damage.

Highlights

Introduction to hypertensive crises and the importance of distinguishing between markedly elevated blood pressure and hypertensive crisis.

Definition of markedly elevated blood pressure as systolic greater than 180 mmHg and diastolic greater than 120 mmHg.

Explanation of hypertensive crisis as elevated blood pressure with evidence of target organ damage.

Importance of investigating clinical signs and symptoms to identify potential target organ damage.

Mention of specific symptoms such as headaches, visual changes, and changes in mental status as indicators of possible stroke.

Concern for chest pain as a potential sign of aortic dissection or other cardiac issues.

Discussion on the necessity of checking for pulmonary edema and other lung issues in the context of hypertensive crises.

Emphasis on the importance of evaluating kidney function and urine output in patients with hypertensive crises.

Recommendation of diagnostic tests such as CBC, CMP, troponin, and imaging studies for patients with hypertensive crises.

Algorithm for treating hypertensive crises with a focus on IV medications and blood pressure reduction goals.

Guidelines for reducing blood pressure by no more than 25% in the first hour and the rationale behind this approach.

Differentiation between treating hypertensive urgency in outpatient settings versus hypertensive emergencies requiring ICU admission.

Special considerations for treating hypertensive crises in specific clinical scenarios such as ischemic strokes, hemorrhagic strokes, aortic dissection, and preeclampsia/eclampsia.

Emphasis on the importance of not dropping blood pressure too rapidly to prevent hypoperfusion and ischemia.

Highlight of the need for continuous blood pressure monitoring and the use of arterial lines in severe cases.

Recommendation of specific medications for treating hypertensive crises, including calcium channel blockers, beta blockers, and vasodilators.

Conclusion summarizing the key points of the lecture and the importance of recognizing and treating hypertensive crises appropriately.

Transcripts

welcome to little lectures making

learning and teaching easy for residents

and students on the go join our

residents from the University of

Louisville as they share the highest

yield internal medicine topics in

digestible chunks hi my name is Travis

Huffman I'm a second-year internal

medicine resident here at the University

of Louisville and today we'll be doing a

little lectures on hypertensive crises

today we'll be talking about terms that

you've heard before hyper tons of

urgency and hypertensive emergency but

we'll be referring to them as markedly

elevated blood pressure and hypertensive

crisis respectively both terms are still

in circulation but the accha when they

refer to their treatment they go along

those guidelines of markley elevated

hypertension and hypertensive crisis so

what are we talking about here we're

talking about elevated blood pressure so

how elevated so we're looking at blood

pressure systolic greater than 180

millimeters of mercury and diastolic

pressures greater than 120 and that's an

order doesn't have to be and so you have

this patient that comes in with these

blood pressures and you need to do a

little bit more investigation because

these are severely elevated and this is

kind of the media lecture find out if

there's a cute target and organ damage

so you can find that out the clinical

signs and symptoms and so you wanted to

you know ask your patient in your HMP

and kind of start head down so are they

having any headaches or they have any

visual changes or they have any changes

in mental status these are things gonna

indicate that there's a possible stroke

a bleed entry increased intracranial

pressure so things that make you start

thinking about that and then move down

into the chest you worried about the

heart so if they're having chest pain

that's definitely concerned if they're

having something like a a or a

dissection that's having ripping tearing

chest pain into the back that's

obviously something that you need to to

be concerned about and the lungs are

they having short of breath indicating

like pulmonary edema in the abdomen or

they have a knowledge of vomiting that

can be from increased intracranial

pressure as well as from some benign

hemorrhage or not benign but some

hemorrhage and then with the kidneys if

they have a change in color of urine

like he materia or decreased urine

output like a lagoon so once you've

decided that there are symptoms and then

you can work up kind of the signs on a

focus base it's a good idea to get a CBC

a CMP look at the haemoglobin see if

there's a drop look at the kidney

function see if there's an acute kidney

injury with

increase in the creatinine then you

could get some troponin looking at if

there's any sub into cardio ski me or am

I going on that would cause a leak of

troponin get a you a look for hematuria

look for red cell casts and then imaging

wise if you're worried about a stroke

you want to get a CT head without make

sure they're not bleeding good then the

CT head width or an MRI if you're

looking for an ischemic stroke get a

chest x-ray start off the bat make sure

that there's no widened mediastinum that

would indicate a cute aortic dissection

or any fluid in the lungs that would

indicate LV failure and pulmonary edema

and then if you're really concerned

about acute aortic dissection you can

work them up with a CT a an MRA or T CTA

is gonna be the best but kidney function

doesn't allow so and then move away from

that but again that's kind of the point

you have this person with very high

elevated blood pressures you need to

find out if there's targeted organ

damage if there is that's hypertensive

crisis so that's that definition

elevated blood pressures with target and

organ damage if they're asymptomatic and

doing well and that's markedly elevated

blood pressure and so you'll see that

quite common in the outpatient setting

patients will come in you'll see their

vitals they'll be very elevated you know

it's always a good idea to recheck a

manual and then going from there you

want to see again if they're having

signs and symptoms but they're not they

can be treated as an outpatient if

they're compliant you can intensify

their regimen if they're non-compliant

then you want to just give them their

home medications because if you start

adding stuff you run the risk of

hypotension so just be cautious with

that but we'll go into a whole other

lecture about blood pressure medications

specifically in the outpatient setting

so in the inpatient what are you going

to do when you have hypertensive urgency

or a hypertensive emergency in crisis

you have somebody with and organ damage

you're going to want to treat them with

IP antihypertensives you're going to

want to place an arterial line and get

continuous blood pressure monitoring and

they're going to need to be admitted to

the ICU now we follow an algorithm that

will only be excluded if there's really

four clinical scenarios that we'll talk

about at the end and so this algorithm

is based off of using IV medications and

usually on a drip and those can be IV

calcium channel blockers like not Carter

pain

IV beta blockers like labetalol our tio

vasodilators like nitroprusside

vino dilators hydralazine nitroglycerine

these are going to be medications that

we can use to acutely drop this

pressure and our algorithm is going to

be based off gold so we're gonna set a

goal in the first hour and this is based

off what the accha recommends to drop

the blood pressure by no more than 25%

in that first hour so calculate the SPP

or calculate the map calculate your goal

which will be you know less than 25% of

that and that's your target in the first

hour now if they're stable then you can

drop it over the next two to six hours

less than 160 systolic and less than 110

diastolic after that over the next 24 to

48 hours you can titrate them down to

normal blood pressure and transition to

Pio medications there's an alternate

regimen that's still publishing

up-to-date with updated guidelines and

it still falls in that in that window

where you can do 10 to 15% reduction in

the first hour 10 to 15 percent over the

next 23 hours and then back to normal of

a pusher and 24 to 48 hours

either way the whole idea is let's not

just drop their blood pressure

completely and hypoperfusion

specifically the brain and cause

ischemia and damage that way so the you

know we we follow this regimented plan

in order to protect those organs from

hypoperfusion that have compensated for

this elevated blood pressure so I

referred to some situations that you

want to recognize and there's really

four big ones because that will change

an alter your treatment and so those are

strokes specifically ischemic strokes

and regards to permissible hypertension

so we don't want they already have a

schema damage we don't wanna drop the

blood pressure and make it worse so if

they're gonna get TPA they can they need

to be less than 185 over 110 prior to

administration and then for an

additional 24 hours afterwards if

they're not getting TPA so if they have

a contraindication they don't have to

have their blood pressure lowered unless

it's greater than 220 systolic it's

actually a class 1 recommendation not to

lower the blood pressure because of a

worsening damage and so that's ischemic

strokes also with hemorrhagic strokes

we're gonna acutely drop the blood

pressure with a goal less than 140 in

the first hour

definitely call your folks over at

neurology so they can help guide you

with that you don't want to be you know

making big changes hundred hemorrhagic

strokes without their input a QA or

dissection so again ripping chest pain

radiating into the back that is

something that gets worse with

hypertension

blood pressure causes worse in the

myelin tearing and worse bleeding and

hemorrhage into the vessels so what we

want to do is acutely drop that very

aggressively and we can drop that less

than 120 systolic in the first 20 to 40

minutes at least less than 140 in the

first hour though and for thoracic

things like that the ACA a CC and a H a

both recommend using IV labetalol so you

get some beta blockade in there as well

and then with your pregnant patients as

your other third clinical situation

preeclampsia eclampsia you're gonna want

to use medications that are safe and

pregnancy hydralazine methyl dope

labetalol

and nifedipine are the best and so less

than 140 systolic in the first hour but

absolutely call OB that's always a good

idea and then pheochromocytoma is your

last one so headaches palpitations and

intermittent severe hypertension you're

going to want to alpha blockade them

first in beta blockade them and you're

gonna do that with a goal less than 140

in that first hour so if it's outside of

those four parameters you're gonna

follow the regular algorithm so a quick

recap with three take-home points from

this lecture will be to understand and

identify what severely Hyper's elevated

hypertension is in regards to their

definition of a systolic greater than

180 millimeters of mercury and greater

than 120 on the diastolic and remember

that's an or also to discover whether

there is end organ damage and so if you

have established that there's end organ

damage you want them to be admitted to

the ICU and treated impatient if there's

not treated as an outpatient then the

third take-home point is to recognize

the four clinical situations in which we

alter from our regimen and those will be

acute aortic dissection ischemic and

hemorrhagic strokes pheochromocytoma and

preeclampsia eclampsia so pregnant

patients with severely elevated hyper

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