Hypertension (Uncontrolled) and Hypertensive Crisis

Definition/Etiology:

• Definition
  • Hypertension is when blood pressure, the force of blood flowing through blood vessels, is persistently too high.
  • Analogy
    • How is blood pressure like a garden hose? Think of blood pressure in your vessels like water in a garden hose. Ever put your thumb over the end of a garden hose? Water = more force but there’s less of it.
    • POOR PERFUSION.
  • Tested PCCN Stages of HTN
    • Stage 2-When patients become symptomatic – leads to organ damage
      • 140/90 -taken on two separate events
    • HTN CRISIS – Organs are at immediate risk/Poor Compliance
      • 180/120
• Etiology/Cause
  • Primary (90%) Idiopathic
  • Secondary (10%)
    • Renal Disease
    • Anything that causes Atherosclerosis
      • Hyperlipidemia, smoking, obesity, stress etc
    • Endocrine Disorders
      • Cushing’s (↑ Aldosterone)

Pathophysiology:

• Blood pressure is a result of Cardiac Output X Peripheral resistance
• Increased Plasma Volume (Too much Fluid)
  • Increased Stroke Volume
  • Increase Systolic Blood Pressure (Raises top BP number)
• Increased vasoconstriction of Peripheral Arterioles (too much squeeze)
  • Increased Systemic Vascular resistance
  • Increased Diastolic pressure
• When we get to antihypertensives this is what we mostly control.
  • Fluids & Squeeze!

Noticing: Assessment & Recognizing Cues:

• Stage 2 HTN (140/90)
  • “Silent Killer” Asymptomatic until end organ damage SLOWLY occurs
    • Brain – Stroke
    • Retina – Vision Loss
    • Heart – MI/Heart Failure
    • Kidneys – Kidney Failure
      • Kidneys take up 20% Cardiac Output
• HTN CRISIS (180/120)
  • QUICK onset of symptoms
    • Blurred Vision
    • Severe headaches
    • Dizziness
    • Chest Pain/Angina
    • Nosebleeds

Interpreting: Analyzing & Planning:

• Labs
  • Lipid Profile – atherosclerosis
  • Bun/Creatinine – Kidney involvement
  • Aldosterone – Endocrine
  • UA – Protein/blood
• Diagnostics
  • ECG – LVH (big QRS)
  • ECHO – LV Hypertrophy
  • CXR – Cardiomegaly or Pulm Edema
  • CT Brain – HTN Crisis = CVA

Responding: Patient Interventions & Taking Action:

• Bring down SLOWLY
  • Organs are used to high pressure – can cause ischemia/infarct ↓ too quick
• Pharmacological Interventions – 2 or more + drs titrate meds “low and SLOW”
  • HTN -SLOW ONSET
    • ACEs/ARBS – Decrease Afterload
    • Calcium Channel Blockers
    • Diuretics – Get Fluid Out
    • KCL sparing vs wasting
  • Crisis- RAPID ONSET
    • Arterial vasodilators (Hydralazine)
    • Benzos – Valium/Ativan/Xanax
• Adjunct Medical Therapy
  • Cardiology – Plumbing
  • Nephrology = #1 secondary cause

Reflecting: Evaluating Patient Outcomes:

• ABCs/Hemodynamics stable
• Patient feeling – Drop it slow
• End organ perfusion
  • Brain – less confusion/calm
  • Eyes – vision return to normal
  • Heart – Chest pain/ pulmonary
  • Kidneys – 30ml/hr
• Patient education. Non-compliance = Return to ED

Linchpins (Key Points):

• Notice -Symptoms
  • Chronic (Stage 2 HTN) or Acute (Hypertensive Crisis)
• Interpret- Labs/Diagnostics
  • Hypertensive CRISIS + SX of CVA = CT HEAD STAT
• Respond – Pharmacology & Interventions
  • Probably 2 meds – oral vs IV Push
  • Bring BP down slowly
• Reflect
  • Hemodynamics Stable?
  • Signs of Organ damage?(Kidneys!)