High BP seldom warrants acute intervention. Your only concern should be whether this represents a hypertensive emergency or whether the hypertension reflects a more serious underlying process. Anything else should be managed by the primary physician(s) during the daytime.
1. Do you believe the reading? Take BP yourself if in doubt; use the right size cuff.
2. Do a chart biopsy and note the time course of hypertension. Has it been constant since admission, or has it developed suddenly?
3. Rule out underlying conditions causing hypertension based on a chart biopsy and focused H&P. Treat the underlying condition rather than the BP.
- Alcohol withdrawal (tachycardia, tremor, confusion)
- Drug overdose (cocaine, amphetamine)
- Drug interactions (MAO inhibitors, tricyclics)
- Drug withdrawals (blockers, ACE inhibitors, central alpha blockers)
- Increased intracranial pressure (Cushing?s reflex)
- ESRD, renal failure, renal artery stenosis
- Eclampsia, pre-eclampsia (is the patient pregnant?)
- Coarctation of the aorta, aortic dissection (unequal BP in arms?)
- Pheochromocytoma (episodic nature; associated with flushing, diaphoresis, tachycardia)
- Endocrine (Cushing's syndrome, thyrotoxicosis)
4. Hypertensive emergency exists when elevated BP is associated with end-organ damage (brain, eye, heart, and kidney) whereas hypertensive urgency implies an elevated BP of > 200/120 but no evidence of end-organ damage. Ask about and examine:
- Brain: headache, confusion, lethargy, stroke
- Eye: blurred vision, papilledema, flame hemorrhages
- Heart: chest pain, SOB, S3, S4, ECG strain or ischemic changes
- Kidney: low urine output, edema, hematuria
5. Hypertensive emergencies require admission to the ICU and reduction of BP by 25% over 6-12 hours with IV medications. Your choices include:
- Nitroprusside 0.3 mcg/kg/min and titrate up (requires arterial line BP monitoring and ICU stay).
- Labetolol 20 mg IV q10 min until BP down; alternatively, infusion dosed at 0.5 ? 3.0 mg/min.
- Nitroglycerin 5 mcg/min and titrate up (use when heart disease present; requires ICU stay).
6. For hypertensive urgencies, remember that in a patient who has "lived at this level" of hypertension for a while, a large acute reduction in BP may change an asymptomatic patient into a symptomatic one (precipitate cerebral/myocardial ischemia). If you decide to intervene, suggestions include:
- Nitropaste is easy and can be easily removed (but can cause HA); see Sliding Scales: Nitropaste; captopril 6.25-25 mg po TID (check K, Cr, allergies before); Clonidine 0.1 mg po bid.
- Avoid short-acting nifedipine (increased mortality).
7. Special situation: In patients with an acute CNS process (i.e. during/post-CVA), HTN is usually compensatory and should be permitted as long as the BP is < 220/110.
Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356:411-7.
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