Acute Hypertension (Rapid Response Calls)

foreign crash course I'm discussing acute hypertension specifically how to approach a hypertensive crisis that occurs in a patient already admitted to the hospital unlike some other entries in this particular video series a hypertensive crisis in the hospital more commonly triggers an ASAP page to the covering clinician rather than a full rapid response code but the principles to approaching it are otherwise similar imagine that as the resident on call at night you've finally gone to your call room and are laying down hoping for an hour or two of sleep when you get this page Zoom it from F3 calling regarding patient Campos his blood pressure is 210 over 130 it was 150 over 94 hours ago heart rate is 86 O2 sat 98 patient denies symptoms but is more confused bedside eval requested ASAP as you put your shoes and Patagonia fleece back on you head out to the wards and start thinking through all the possible explanations for an acute rise in an inpatient's blood pressure you could put etiologies of acute inpatient hypertension into a few categories under cardiovascular the patient may simply have previously unrecognized uncontrolled hypertension for example a patient without access to Primary Care could be emitted for an infection or some cause of dehydration their pressure at the time of admission looked normal but that was because of their acute illness then they received IV fluids plus or minus antibiotics and now 12 or 24 hours later their pressure is back to what is more typical for the patient alternatively the patient could be on appropriate antihypertensives as an outpatient but they were not ordered on admission this could either have been due to an error with medication reconciliation or because emitting doctors were excessively worried about the potential development of hypotension in the setting of infection and therefore held these meds intentionally acute inpatient hypertension can also be due to medication or drug effect in this category is drug intoxication with cocaine and amphetamines drug withdrawal from alcohol or benzodiazepines hypertension can also be a manifestation of serotonin syndrome and neuroleptic malignant syndrome under neural causes are acute Strokes any cause of high intracranial pressure and a condition called autonomic dysreflexia which is a chronic condition seen in patients following High spinal cord injuries which they experience an inappropriate surge of sympathetic activity in response to a visceral stimulus originating from below the injury such as bladder distension last are other etiologies including any cause of hyperactive delirium acute kidney injury anxiety and uncontrolled pain in my experience as a hospitalist at a U.S tertiary Care Center the most common etiologies of acute hypertension that I see are uncontrolled primary hypertension a lack of the patient's outpatient antihypertensives alcohol withdrawal hyperactive delirium and inadequately controlled pain when evaluating a patient with acute hypertension it is critical to distinguish between hypertensive urgency and hypertensive emergency in urgency the blood pressure is extremely elevated but the patient is without symptoms or evidence of secondary organ dysfunction whereas an emergency the patient is either experiencing symptoms such as severe headache confusion chest pain or shortness of breath or the patient has objective evidence of organ damage such as hematuria retinal hemorrhages an elevated troponin or has develop something like the pregnancy complication of preeclampsia so now you've arrived at Mr campus's room and you find him as described in bed confused and a little agitated but otherwise denying symptoms where do you go from here a clinical challenge with evaluating acute hypertension particularly hypertensive emergency which this would likely count as is to distinguished findings that suggest an etiology of the hypertension from a complication of the hypertension so what do I mean by that let's consider some components of the history including symptoms of the patient if the patient has a history of recent alcohol use that obviously suggests that alcohol withdrawal could be the ideology and if the patient has a history of spinal cord injury that suggests that it could be autonomic dysreflexia but what if the patient is reporting chest pain on one hand chest pain can be a symptom of anxiety suggesting that anxiety is the cause of the hypertension on the other hand chest pain can be a symptom of demand ischemia or even in aortic dissection which could be the result of the hypertension it's the same with dyspnea which could indicate anxiety or alternatively could suggest that the acute hypertension is leading to acute heart failure what about on exam bradycardia and slow irregular respirations are part of Cushing's Triad along with hypertension that could signal an underlying etiology of high intracranial pressure or the acute hypertension was from something else completely unrelated led to an intracranial hemorrhage and that's now why the patient is bradycardic and breathing slowly the same for the presence of a focal neural finding such as unilateral weakness or aphasia or the presence of confusion Plus somnolence whereas the combination of confusion plus agitation as in this patient can suggest alcohol withdrawal serotonin syndrome neuroleptic malignant syndrome hyperactive delirium or uncontrolled psychiatric disease while this combination could alternatively be the consequence of hypertensive encephalopathy or a condition called posterior reversible encephalopathy syndrome or press the presence of bilateral crackles and elevated jvp are consistent with the secondary development of acute heart failure of course none of these are mutually exclusive for example alcohol withdrawal in a patient with severe coronary disease could trigger acute hypertension leading to demand ischemia and chest pain which then triggers worsened anxiety and the anxiety Then worsens the hypertension in a positive feedback cycle when it comes to the workup of acute hypertension Diagnostics are driven by symptoms and signs no symptoms or physical signs usually means no additional Diagnostics are necessary otherwise indicated tests flow naturally from your bedside assessment so the patient has chest pain an ECG and troponin shortness of breath means a chest x-ray as well as an ECG entroponin acute hypertension with either a focal neural finding or confusion plus ambulance should be evaluated with a head CT the one trickier situation is a combination of acute hypertension confusion and agitation most of these patients do not require neural Imaging but some might depending on the suspicion for a condition like press or an atypical presentation of an ischemic stroke or hemorrhage when it comes to the treatment of hypertensive urgency the first consideration is to evaluate and treat the underlying cause in conjunction with that regarding the direct treatment of the blood pressure one could choose to wait 30 minutes and recheck it I I think doctors particularly interns and residents feel pressure to order a medication when a nurse pages about a patient with hypertension but without symptoms or signs of organ dysfunction you have time you don't need to necessarily do something at that exact moment acknowledging the nurse's concern thanking them for letting you know but politely explaining why you are going to hold off on a new Med at this moment is an okay approach most of the time alternatively if the patient is on antihypertensives already you could give the next dose a little early you could also intensify the oral antihypertensive regimen so restarting or up titrating outpatient meds particularly if they aren't currently on their regular outpatient regimen or this could mean starting a completely new oral anti-pretensive this last option is generally the least desirable one particularly for patients in whom you as the responding doctor are just cross covering while the patient's regular team is not in the hospital I would only recommend doing this if there is already clear evidence that the patient will need better blood pressure control as an outpatient following discharge if you do decide to actively treat hypertensive urgency intravenous meds are usually not indicated but there are several notable exceptions in which more aggressive blood pressure lowering is indicated for example recent neurovascular or cardiac surgery we use an intracranial hemorrhage patients who are at a high risk of developing flash pulmonary edema such as patients with severe mitral regurgitation and patients with truly profound elevations of blood pressure now I wish I could give a specific cut off here but as far as I know there is no good data on what blood pressure is high enough to Warrant emergent lowering despite an absence of symptoms but whatever it would be it would be highly unusual not just as a stock pressure of 180 or 200. something higher than that alternatively if the patient is experiencing a true hypertensive emergency intravenous medications are usually indicated the goal with meds is to balance the reduction of end organ damage with risks from excessively rapided lowering of the blood pressure which are non-negligible and can include stroke a typical approach is to aim for a reduction in the blood pressure by 10 to 20 percent within the first hour and another five to fifteen percent within the next day so for example in a patient presenting with hypertensive emergency and a blood pressure of 220 over 120 you might bring that down to 190 over 100 over the first hour and then down to 170 over 90 by the following day although you also need to frequently reassess the patient to see how they're responding once symptoms resolve you could consider being less aggressive whereas if symptoms are not responding after an hour or two despite successfully lowering the blood pressure at the intended rate you may need to be more aggressive plus there are some other notable exceptions for example in patients with ischemic Strokes you want to be less aggressive than this possibly electing to temporarily hold off on lowering the blood pressure at all whereas with an aortic dissection you would want to be much more aggressive in addition to your immersion consult to vascular surgery regarding the options for emergent blood pressure control there are many to choose from each with their advantages and disadvantages and their typical indications and contraindications here's a chart of the nine that I've seen most commonly used over the last decade here in the U.S I'm not going to read through the whole table Box by box but with a broad sweeping generalization based on my own anecdotal experience the medical ICU typically relies most on nitropresside and the calcium channel blockers dicardipine and clavidipine the CCU and Cardiology service most commonly uses nitroglycerin and the medicine service most commonly uses labetalol and metoprolol but it does highly depend on what the patient's comorbidities are I'll end with some common pitfalls with acute inpatient hypertension over aggressive treatment of hypertensive urgency excessively rapid lowering of blood pressure and last an over-reliance on IV hydralazine which actually leads to both of the preceding pitfalls you may have noticed that I haven't mentioned hydralazine up until now although it is a common medication Choice by medical house staff to treat hypertension in the hospital it leads to reflex tachycardia can result in an excessively rapid blood pressure drop and is rarely the best option for patients foreign

Channel: Strong Medicine

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Length: 13min 21sec (801 seconds)

Published: Wed Mar 22 2023