Hypertensive Crisis with Dr. Travis Huffman
Summary
TLDRIn 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
🩺 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.
💡 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.
Mindmap
Keywords
💡Hypertensive crises
💡Markedly elevated blood pressure
💡Hypertensive emergency
💡End-organ damage
💡Intracranial pressure
💡Aortic dissection
💡Pulmonary edema
💡Preeclampsia/Eclampsia
💡Pheochromocytoma
💡IV antihypertensives
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
attachment I hope you all enjoyed this
thanks for listening thanks for
listening and learning with us if you
would like more information on this
topic please take a look at our
full-sized Louisville lectures either on
Louisville lectures org on our youtube
channel or on our podcast
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