Handout – Hypertensive Emergencies Hypertensive Emergency BP

Handout – Hypertensive Emergencies
BP goals
The Evidence
Ischemic Stroke
Case 1:
You are at the PLC seeing a patient in WRC. Mrs. Dhaliwal is a 53 yo female who
speaks limited English, and is in with her daughter. She had been seen at FMC by a
colleague 3 days prior, and referred to urgent neurology clinic. She has been
experiencing headache and numbness to her right arm intermittently for the past
week, and has had episodes of dizziness and poor coordination. She has returned
today feeling unwell. You are waiting to receive the chart from FMC with the details
of this visit.
You scan her vitals and her BP is 170/105. Her neurological and cardiovascular
examination is normal. Her ECG is unremarkable.
1) What do you want to do about this blood pressure?
2) What investigations do you want to order? (EO dysfunction)
You order your tests and go and see another patient. The nurse pages you back to
RAZ, who tells you her blood pressure is even higher, at 190/115. She is
complaining of a worsening headache, and her daughter tells you she seems to be a
bit confused. You re-examine her and find new right-sided upper extremity
weakness and some poor coordination in her right hand. You search for the
panoptic for fundoscopy, but it has taken a walk-about and you can’t find it. You also
arrange a CT head.
3) What is her diagnosis?
4) How do you want to treat her blood pressure? What 2 agents can you use in
this case, and what is your BP / MAP goal?
5) What are 2 contra-indications to using sodium nitroprusside?
Case 2:
It’s a Friday night at PLC, and it has been slow. You are wishing you had taken the
shift at FMC, you hear there’s been 2 stabbings and a thoracotomy over there! Damn.
After seeing your fifth WRC patient, you sign up for a patient in B2. Julius is a 55 yo
male from Kenya. He has been feeling unwell for several days, with some shortness
of breath and uncomfortable sensation in his chest.
You are concerned as you eyeball him. He is in moderate respiratory distress. You
quickly examine him and find bilateral crackles, an elevated JVP and mild pitting
edema. His BP on the monitor reads 235/130, HR120, SaO2 99% 8L NP. Your ECG
and CXR are below, trops are pending.
1) How do you calculate the mean arterial pressure? What is Julius’s MAP?
2) Are you worried about his vital signs in this clinical context, why?
3) Your tnt comes in and is 0.90. How are you going to manage this patient?
What are your BP goals and what is your first line agent?
4) Would you beta block this patient?
Case 3:
You decide to do an elective in Cranbrook. After all the great trauma and interesting
medical cases you see coming from there, you figure it’s the place to be. Your first
patient is a 59 yo long haul trucker named Dave. On the way to the bathroom this
morning Dave had sudden onset of weakness his left arm and leg and a facial droop.
He called 911 and is now sitting in your emergency department 30min after the
onset of his symptoms.
Upon his arrival to the ER, he is taken urgently to the CT scanner. CTA shows a right
MCA occlusion. You decide he needs tpa then transfer to FMC.
Dave is awake, alert, and oriented. His VS are as follows:
HR 90 BP225/115 RR16 SaO2 99% NP
1. What do you think about Dave’s BP?
2. What is your BP goal?
3. As your nurse is drawing up the tpa, you learn that Dave had a trauma 1
month ago in a dirt bike accident where he sustained a small traumatic
subdural hematoma, resolved on CT today. Does this change the management
of his BP?
4. What 3 agents can you use to treat his blood pressure in either scenario, and
which is your first line therapy?
Dave does not get TPa and is transferred to FMC. He recovers some of his function,
but has persistent disability. He goes back to Cranbrook for ongoing stroke rehab.
Case 4:
You are working at FMC when Linda, a 75 yo woman with a history of hypertension
presents with headache, confusion, and dysphasia. Her husband called 911 and she
is brought to the ED. Before you have a chance to see her, the stroke team rushes her
off to the scanner, and her head CT is below.
When she returns from CT she has a decreased level of consciousness, with a GCS 8
so you intubate her. 10 minutes after intubation and despite being on propofol her
BP is still 230/110.
1) Are you going to lower her BP? If so, what are your BP goals?
2) What agent are you going to use? What agent should you avoid and why?
3) If anything, what worries you the most about lowering the BP?
Case 5:
You are working at FMC. Your next patient is in bed 15. She is a 71yo F who felt
weak and dizzy and had a syncopal episode at home, associated with some chest and
back pain. Initially with EMS there had been a question of left sided weakness, which
has now resolved. Her past medical Hx is significant for hypertension and
dyslipidemia. You are concerned about the possibility of aortic dissection given the
story, and send her for CT angio of chest and neck. Her CT is below. When she gets
back from CT the BP in her left arm remains persistently elevated at 160/100, but
the BP on the right is 90/50.
1) What do you see on CT? Who you gonna call?
2) You have called cardiac surgery and they are on their way in. They ask you to
manage the BP. Are you concerned about the BP in this scenario? Which BP
reading should you use to guide therapy?
3) What agent will you use first and why? What are your BP goals?
4) You treat her BP and it is now 130/90, HR 60. What’s your plan now doctor?
5) You treat her BP to a goal you are happy with, and she now has persistent left
sided weakness. You repeat a CT scan of here head, which shows a right
sided cerebral infarct. What do you want to do with her BP management
Case 6:
You are a disgruntled resident, a bit fed up with life half way through residency. As a
favor to yourself and your loved ones, you decide to leave town for an elective in
Revelstoke, BC. You are so stoked for all the skiing you are going to do.
It’s your first night on call for the emergency department, and you are called in to
see a young woman who is unwell. Chalrie is a 25 yo female who presents with
nausea, vomiting, and is achy all over, especially her head. The nurse tells you she
has gastro. You see she is holding a cute little baby in her arms, and Charlie tells you
she is 3 weeks old.
You glance at the chart before examining her. Her BP is 160/105. You think that’s a
little odd.
1. What else do you want to know on history and physical exam?
2. What investigations do you wan to order? Your lab technician is sleeping at
home, but you can get a urine right now.
3. What is your diagnosis? You call your preceptor for help, but to your dismay
he has taken off to Rogers pass for the night; they figured you are a resident
form the city, you got it covered.
4. How are you going to manage Charlie? If any, what are your BP goals, and if
you treat her BP what 2 agents will you use?
5. Will you give Charlie magnesium sulfate?