Optimal Management of Hypertensive Emergency Patients: Clinical Scenarios and Panel Discussion

1. Optimal Management of Hypertensive Emergency Patients: Clinical Scenarios and Panel Discussion

2. 2010 Clinical Decision Making in Emergency MedicinePonte Vedra Beach, FLJune 24, 2010 Clinical Decision Making in Emergency Medicine – A N  E V I D EN C E - B A S E D  C O N F E R E N C E

3. www.ferne.org

4. Edward P. Sloan, MD, MPH FACEPProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL

5. Attending PhysicianEmergency MedicineUniversity of Illinois HospitalSwedish American Belvidere HospitalChicago, IL

6. Panelists • Dr. Bradshaw Bunney: • Associate Professor University of Illinois • Department of Emergency Medicine • FERNE Executive Board • Genentech Speakers’ Bureau • Dr. Heather Prendergast: • Associate Professor University of Illinois • Department of Emergency Medicine • FERNE Executive Board • No individual financial disclosures

7. Panelists • Dr. Andy Jagoda: • Professor and Chair • Mt Sinai Department of Emergency Medicine, NY • FERNE Executive Board • Dr. Scott Silvers: • Chair, Emergency Department • Mayo Clinic Jacksonville, FL • FERNE Executive Board

8. Disclosures • FERNE Chairman and President • FERNE advisory board for The Medicine Company in May 2007 • FERNE grant by The Medicines Company to support this program • No individual financial disclosures

9. Disclosures • Jagoda: Past work with The Medicines Company in 2007 • Bunney: Genentech • Prendergast: None • Silvers: None • No other individual financial disclosures

10. Thank You • Clinical Decisions in EM Consortium • Well assembled staff • EB Medicine • The Medicines Company • FERNE staff • Panelists • All of you

11. Hypertensive Crisis • Hypertensive urgency: • elevation of blood pressure without acute end organ damage • Hypertensive emergency • elevation of blood pressure with acute end organ damage • Diastolic BP usually >120 in both instances

12. Q: Who/what do you treat? • Do you treat the pt or the number? • 1. Patient • 2. Number • 3. Patient, but if pressed, I will treat the number regardless

13. Q: What number do you treat? • Do you treat SBP, DBP, or MAP? • 1. SBP • 2. DBP • 3. MAP

14. Q: Mean Arterial Pressure • Do you know how to calculate MAP? • 1. Yes • 2. No

15. Q: Mean Arterial Pressure • 1/3 systolic + 2/3 diastolic • 180/120 = 60 + 80 = 140 MAP • 120/90 = 40 + 60 = 100 MAP

16. Q: Diastolic BP • Above what diastolic BP will you treat a patient, regardless if the pt is asymptomatic and the BP elevation in chronic? • 1. 100 • 2. 110 • 3. 120 • 4. 130 • 5. 140

17. Q: Treatment Endpoint • What is your successful treatment endpoint? • 1. Absolute drop in endpoint BP • 2. % Drop in endpoint BP • 3. Depends on how high BP is • 4. Depends on clinical situation • 5. Varies, not consistent

18. Case 1: Ischemic Stroke A 64 year old male patient with a history of hypertension and diabetes presents to the Emergency Department with a new onset of ipsilateral right-sided facial droop, arm and leg weakness, aphasia, and gaze to the left. His vital signs are BP 230/135, HR110, RR 16, and Temp 98.4.

20. Q: How would you Rx this pt? • What type of anti-hypertensive agent would you use? • 1. Oral • 2. IV bolus • 3. Continuous infusion • 4. Other

21. Q: What IV anti-hypertensive? • What IV bolus agent might you use? • 1. Hydralazine • 2. Labetalol • 3. Enalaprilat • 4. Phentolamine • 5. Other

22. Q: What IV anti-hypertensive? • What IV infusion Rx might you use? • 1. Sodium nitroprusside • 2. Nicardipine • 3. Fenoldopam • 4. NTG • 5. Esmolol • 6. Clevidipine

23. Q: Clinical Rx Endpoint • To what clinical endpoint would you treat this patient? • How? • Why?

24. Case 2: Chest Pain A 68 year old male presents with chest pain, sub-sternal described as severe. Onset less than one hour prior to arrival. Associated with nausea, diaphoresis. No known cardiac history . Patient is a Smoker, ?cholesterol. His vital signs are BP 198/118, HR100, RR 20, and Temp 98.8.

26. Q: How would you Rx this pt? • What type of anti-hypertensive agent would you use? • 1. Oral • 2. IV bolus • 3. Continuous infusion • 4. Other

27. Q: What IV anti-hypertensive? • What IV bolus agent might you use? • 1. Hydralazine • 2. Labetalol • 3. Enalaprilat • 4. Phentolamine • 5. Other

28. Q: What IV anti-hypertensive? • What IV infusion Rx might you use? • 1. Sodium nitroprusside • 2. Nicardipine • 3. Fenoldopam • 4. NTG • 5. Esmolol • 6. Clevidipine

29. Q: Clinical Rx Endpoint • To what clinical endpoint would you treat this patient? • How? • Why?

30. Case 3: Dyspnea A 58 year old female patient with a history of ESRD on dialysis , hypertension, pacemaker and diabetes brought to the Emergency Department by EMS for vomiting and mild frontal headache. Per family, pt missed her last dialysis session. Her vital signs are BP 225/142, HR125, RR 30, and Temp 98.4.

32. Q: How would you Rx this pt? • What type of anti-hypertensive agent would you use? • 1. Oral • 2. IV bolus • 3. Continuous infusion • 4. Other

33. Q: What IV anti-hypertensive? • What IV bolus agent might you use? • 1. Hydralazine • 2. Labetalol • 3. Enalaprilat • 4. Phentolamine • 5. Other

34. Q: What IV anti-hypertensive? • What IV infusion Rx might you use? • 1. Sodium nitroprusside • 2. Nicardipine • 3. Fenoldopam • 4. NTG • 5. Esmolol • 6. Clevidipine

35. Q: Clinical Rx Endpoint • To what clinical endpoint would you treat this patient? • How? • Why?

36. Case 4: AMS/Coma A 49 year old male patient with a history of hypertension presents to the Emergency Department with a thunderclap headache, vomiting, and altered mental status. Upon arrival to the ED, he becomes unresponsive. His vital signs are BP 264/142, HR 90, RR 12, and Temp 98.4.

38. Q: How would you Rx this pt? • What type of anti-hypertensive agent would you use? • 1. Oral • 2. IV bolus • 3. Continuous infusion • 4. Other

39. Q: What IV anti-hypertensive? • What IV bolus agent might you use? • 1. Hydralazine • 2. Labetalol • 3. Enalaprilat • 4. Phentolamine • 5. Other

40. Q: What IV anti-hypertensive? • What IV infusion Rx might you use? • 1. Sodium nitroprusside • 2. Nicardipine • 3. Fenoldopam • 4. NTG • 5. Esmolol • 6. Clevidipine

41. Q: Clinical Rx Endpoint • To what clinical endpoint would you treat this patient? • How? • Why?

42. Case 5: Ankle Pain A 44 year old male patient with no significant past medical history presents to the Emergency Department with acute ankle injury while getting off the bus. Exam shows significant soft tissue swelling to lateral malleolus. His vital signs are BP 197/126, HR 89, RR 16, and Temp 98.4.

44. Q: How would you Rx this pt? • What type of anti-hypertensive agent would you use? • 1. Oral • 2. IV bolus • 3. Continuous infusion • 4. Other

45. Q: What IV anti-hypertensive? • What IV bolus agent might you use? • 1. Hydralazine • 2. Labetalol • 3. Enalaprilat • 4. Phentolamine • 5. Other

46. Q: What IV anti-hypertensive? • What IV infusion Rx might you use? • 1. Sodium nitroprusside • 2. Nicardipine • 3. Fenoldopam • 4. NTG • 5. Esmolol • 6. Clevidipine

47. Q: Clinical Rx Endpoint • To what clinical endpoint would you treat this patient? • How? • Why?

48. Q: Start on HTN Rx • Would you start them on an anti-hypertensive medication? • 1. Yes • 2. No

49. Q: Disposition • What special instruction would you give for follow-up? • Where? • When?

50. Q: ACEP Guideline • Have you read the ACEP HTN guideline ? • 1. Yes • 2. No