Hypertensive Crises: Emergencies and Urgencies -- Printable Tables

TITLE:	HYPERTENSIVE CRISES: EMERGENCIES AND URGENCIES
AUTHOR:	DONALD VIDT, MD -- Department of Nephrology
PUBLISHED:	MARCH 5, 2003

Table 1:
Clinical Characteristics of the Hypertensive Emergency
Blood Pressure	Funduscopic Findings	Neurologic Status	Cardiac Findings	Renal Symptoms	Gastrointestinal Symptoms
Usually >220/140 mm Hg	Hemorrhages, exudates, papilledema	Headache, confusion, somnolence, stupor, visual loss, seizures, focal neurologic deficits, coma	Prominent apical pulsation, cardiac enlargement, congestive heart failure	Azotemia, proteinuria, oliguria	Nausea, vomiting

Table 2:
Triage Evaluation:
	Emergency	vs.	Uncontrolled Hypertension
Blood Pressure	>220/140 mm Hg		>180/120 mm Hg
Symptoms	SOB Chest Pain nocturia dysarthia weakness altered consciousness		Headache SOB epistaxis edema often asypmtomatic
Examination	encephalopathy pulmonary edema renal insufficiency cerebrovascular accident acute coronary syndrome		may have TOD clinical CVD present stable, often no TOD/CVD
Therapy	baseline laboratory tests intravenous line monitor BP may initiate therapy in ED		observe initiate/resume medication(s) increase dose of inadequate agent
Plan	Immediate admission to monitored unit parenteral agents treat to initial goal BP additional diagnostic studies if needed		arrange follow-up <24 hours to several days if no prior evaluation, schedule appointment

Table 3:
Management of Hypertensive Emergencies
Agent	Dose	Onset/Duration of Action (after discontinuation)	Precautions
Parenteral Vasodilators
Sodium nitroprusside	0.25-10 µg/kg/min as IV infusion	Immediate/2-3 min after infusion	Nausea, vomiting; with prolonged use may cause thiocyanate intoxication, methemoglobinemia, acidosis, cyanide poisoning; bags, bottles, and delivery sets must be light resistant
Nitroglycerin	5-100 µg as IV infusion*	2-5 min/5-10 min	Headache, tachycardia, vomiting, flushing, methemoglobinemia; requires special delivery system due to drug binding to PVC tubing
Nicardipine	5-15 mg/hr IV infusion	1-5 min/15-30 min, but may exceed 12 hr after prolonged infusion	Tachycardia, nausea, vomiting, headache, increased intracranial pressure; hypotension may be protracted after prolonged infusions
Diazoxide	50-150 mg as IV bolus, repeated or 15-30 mg/min by IV infusion	2-5 min/3-12 hr	Hypotension, tachycardia, aggravation of angina pectoris, nausea and vomiting, hyperglycemia with repeated injections
Fenoldapam mesylate	0.1-0.3 µg/kg/min IV infusion	<5 min/30 min	Headache, tachycardia, flushing, local phlebitis, dizziness
Hydralazine	5-20 mg as IV bolus or 10-40 mg IM; repeat every 4-6 hr	10 min IV/>1hr (IV) 20-30 min IM/4-6 hr (IM)	Tachycardia, headache, vomiting, aggravation of angina pectoris, sodium & water retention and increased intracranial pressure
Enalaprilat	0.625-1.25 mg every 6 hr IV	Within 30 min/12-24 hr	Renal failure in patients with bilateral renal artery stenosis, hypotension
Parenteral Adrenergic Inhibitors
Labetalol	20-40 mg as IV bolus every 10 min; up to 2 mg/min as IV infusion	5-10 min/2-6 hr	Bronchoconstriction, heart block, orthostatic hypotension, bradycardia
Esmolol	500 µg/kg bolus injection IV or 50-100 µg/kg/min by infusion. May repeat bolus after 5 min or increase infusion rate to 300 µg/kg/min	1-5 min/15-30 min	First-degree heart block, congestive heart failure, asthma
Phentolamine	5-10 mg as IV bolus	1-2 min/10-30 min	Tachycardia, orthostatic hypotension
* Requires special delivery system hr=hour(s); min=minute; IV=intravenous; IM=intramuscular; PVC=polyvinyl chloride

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