Optimal Management Optimal Management of Hypertensive of Hypertensive

Emergency Patients: Emergency Patients: Clinical Scenarios and Panel Clinical Scenarios and Panel

DiscussionDiscussion

2010 Clinical Decision Making in Emergency Medicine

Ponte Vedra Beach, FLPonte Vedra Beach, FL

June 24, 2010June 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

www.ferne.orgwww.ferne.org

Edward P. Sloan, MD, MPH FACEP

Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL

Attending PhysicianEmergency Medicine

University of Illinois HospitalSwedish American Belvidere Hospital

Chicago, IL

PanelistsPanelists• Dr. Bradshaw Bunney:Dr. Bradshaw Bunney:• Associate Professor University of IllinoisAssociate Professor University of Illinois• Department of Emergency MedicineDepartment of Emergency Medicine• FERNE Executive BoardFERNE Executive Board• Genentech Speakers’ BureauGenentech Speakers’ Bureau

• Dr. Heather Prendergast:Dr. Heather Prendergast:• Associate Professor University of IllinoisAssociate Professor University of Illinois• Department of Emergency MedicineDepartment of Emergency Medicine• FERNE Executive BoardFERNE Executive Board• No individual financial disclosuresNo individual financial disclosures

PanelistsPanelists• Dr. Andy Jagoda:Dr. Andy Jagoda:• Professor and ChairProfessor and Chair• Mt Sinai Department of Emergency Medicine, NYMt Sinai Department of Emergency Medicine, NY• FERNE Executive BoardFERNE Executive Board

• Dr. Scott Silvers:Dr. Scott Silvers:• Chair, Emergency DepartmentChair, Emergency Department• Mayo Clinic Jacksonville, FLMayo Clinic Jacksonville, FL• FERNE Executive BoardFERNE Executive Board

DisclosuresDisclosures• FERNE Chairman and PresidentFERNE Chairman and President• FERNE advisory board for The Medicine FERNE advisory board for The Medicine

Company in May 2007Company in May 2007• FERNE grant by The Medicines Company to FERNE grant by The Medicines Company to

support this programsupport this program

• No individual financial disclosuresNo individual financial disclosures

DisclosuresDisclosures• Jagoda: Past work with The Medicines Jagoda: Past work with The Medicines

Company in 2007Company in 2007• Bunney: GenentechBunney: Genentech• Prendergast: NonePrendergast: None• Silvers: NoneSilvers: None

• No other individual financial disclosuresNo other individual financial disclosures

Thank YouThank You• Clinical Decisions in EM ConsortiumClinical Decisions in EM Consortium• Well assembled staffWell assembled staff• EB MedicineEB Medicine• The Medicines CompanyThe Medicines Company• FERNE staffFERNE staff• PanelistsPanelists• All of youAll of you

Hypertensive CrisisHypertensive Crisis• Hypertensive urgency:Hypertensive urgency:

• elevation of blood pressure elevation of blood pressure without acute end organ damagewithout acute end organ damage

• Hypertensive emergencyHypertensive emergency• elevation of blood pressure with elevation of blood pressure with

acute end organ damageacute end organ damage• Diastolic BP usually >120 in both Diastolic BP usually >120 in both

instancesinstances

Q: Who/what do you treat?Q: Who/what do you treat?• Do you treat the pt or the number?Do you treat the pt or the number?

• 1. Patient1. Patient

• 2. Number2. Number

• 3. Patient, but if pressed, I will treat 3. Patient, but if pressed, I will treat the number regardlessthe number regardless

Q: What number do you treat?Q: What number do you treat?• Do you treat SBP, DBP, or MAP?Do you treat SBP, DBP, or MAP?

• 1. SBP1. SBP

• 2. DBP2. DBP

• 3. MAP3. MAP

Q: Mean Arterial PressureQ: Mean Arterial Pressure• Do you know how to calculate MAP?Do you know how to calculate MAP?

• 1. Yes1. Yes

• 2. No2. No

Q: Mean Arterial PressureQ: Mean Arterial Pressure• 1/3 systolic + 2/3 diastolic1/3 systolic + 2/3 diastolic

• 180/120 = 60 + 80 = 140 MAP180/120 = 60 + 80 = 140 MAP

• 120/90 = 40 + 60 = 100 MAP120/90 = 40 + 60 = 100 MAP

Q: Diastolic BPQ: Diastolic BP• Above what diastolic BP will you Above what diastolic BP will you

treat a patient, regardless if the pt is treat a patient, regardless if the pt is asymptomatic and the BP elevation asymptomatic and the BP elevation in chronic?in chronic?

• 1. 1001. 100• 2. 1102. 110• 3. 1203. 120• 4. 1304. 130• 5. 1405. 140

Q: Treatment EndpointQ: Treatment Endpoint• What is your successful treatment What is your successful treatment

endpoint?endpoint?

• 1. Absolute drop in endpoint BP1. Absolute drop in endpoint BP• 2. % Drop in endpoint BP2. % Drop in endpoint BP• 3. Depends on how high BP is3. Depends on how high BP is• 4. Depends on clinical situation4. Depends on clinical situation• 5. Varies, not consistent5. Varies, not consistent

Case 1: Ischemic StrokeCase 1: Ischemic Stroke• A 64 year old male patient with a history of A 64 year old male patient with a history of

hypertension and diabetes presents to the hypertension and diabetes presents to the Emergency Department with a new onset of Emergency Department with a new onset of ipsilateral right-sided facial droop, arm and ipsilateral right-sided facial droop, arm and leg weakness, aphasia, and gaze to the left. leg weakness, aphasia, and gaze to the left.

• His vital signs are BP 230/135, HR110, RR His vital signs are BP 230/135, HR110, RR 16, and Temp 98.4.16, and Temp 98.4.

Q: How would you Rx this pt?Q: How would you Rx this pt?• What type of anti-hypertensive agent What type of anti-hypertensive agent

would you use?would you use?

• 1. Oral1. Oral

• 2. IV bolus2. IV bolus

• 3. Continuous infusion3. Continuous infusion

• 4. Other4. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV bolus agent might you use?What IV bolus agent might you use?

• 1. Hydralazine1. Hydralazine

• 2. Labetalol2. Labetalol

• 3. Enalaprilat3. Enalaprilat

• 4. Phentolamine4. Phentolamine

• 5. Other5. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV infusion Rx might you use?What IV infusion Rx might you use?

• 1. Sodium nitroprusside1. Sodium nitroprusside

• 2. Nicardipine2. Nicardipine

• 3. Fenoldopam3. Fenoldopam

• 4. NTG4. NTG

• 5. Esmolol5. Esmolol

• 6. Clevidipine6. Clevidipine

Q: Clinical Rx EndpointQ: Clinical Rx Endpoint• To what clinical endpoint would you To what clinical endpoint would you

treat this patient?treat this patient?

• How?How?

• Why?Why?

Case 2: Chest PainCase 2: Chest Pain• A 68 year old male presents with chest A 68 year old male presents with chest

pain, sub-sternal described as severe. pain, sub-sternal described as severe. Onset less than one hour prior to Onset less than one hour prior to arrival. Associated with nausea, arrival. Associated with nausea, diaphoresis. No known cardiac history . diaphoresis. No known cardiac history . Patient is a Smoker, ?cholesterol. Patient is a Smoker, ?cholesterol.

• His vital signs are BP 198/118, HR100, His vital signs are BP 198/118, HR100, RR 20, and Temp 98.8.RR 20, and Temp 98.8.

Q: How would you Rx this pt?Q: How would you Rx this pt?• What type of anti-hypertensive agent What type of anti-hypertensive agent

would you use?would you use?

• 1. Oral1. Oral

• 2. IV bolus2. IV bolus

• 3. Continuous infusion3. Continuous infusion

• 4. Other4. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV bolus agent might you use?What IV bolus agent might you use?

• 1. Hydralazine1. Hydralazine

• 2. Labetalol2. Labetalol

• 3. Enalaprilat3. Enalaprilat

• 4. Phentolamine4. Phentolamine

• 5. Other5. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV infusion Rx might you use?What IV infusion Rx might you use?

• 1. Sodium nitroprusside1. Sodium nitroprusside

• 2. Nicardipine2. Nicardipine

• 3. Fenoldopam3. Fenoldopam

• 4. NTG4. NTG

• 5. Esmolol5. Esmolol

• 6. Clevidipine6. Clevidipine

Q: Clinical Rx EndpointQ: Clinical Rx Endpoint• To what clinical endpoint would you To what clinical endpoint would you

treat this patient?treat this patient?

• How?How?

• Why?Why?

Case 3: DyspneaCase 3: Dyspnea• A 58 year old female patient with a A 58 year old female patient with a

history of ESRD on dialysis , history of ESRD on dialysis , hypertension, pacemaker and diabetes hypertension, pacemaker and diabetes brought to the Emergency Department brought to the Emergency Department by EMS for vomiting and mild frontal by EMS for vomiting and mild frontal headache. Per family, pt missed her last headache. Per family, pt missed her last dialysis session. dialysis session.

• Her vital signs are BP 225/142, HR125, Her vital signs are BP 225/142, HR125, RR 30, and Temp 98.4.RR 30, and Temp 98.4.

Q: How would you Rx this pt?Q: How would you Rx this pt?• What type of anti-hypertensive agent What type of anti-hypertensive agent

would you use?would you use?

• 1. Oral1. Oral

• 2. IV bolus2. IV bolus

• 3. Continuous infusion3. Continuous infusion

• 4. Other4. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV bolus agent might you use?What IV bolus agent might you use?

• 1. Hydralazine1. Hydralazine

• 2. Labetalol2. Labetalol

• 3. Enalaprilat3. Enalaprilat

• 4. Phentolamine4. Phentolamine

• 5. Other5. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV infusion Rx might you use?What IV infusion Rx might you use?

• 1. Sodium nitroprusside1. Sodium nitroprusside

• 2. Nicardipine2. Nicardipine

• 3. Fenoldopam3. Fenoldopam

• 4. NTG4. NTG

• 5. Esmolol5. Esmolol

• 6. Clevidipine6. Clevidipine

Q: Clinical Rx EndpointQ: Clinical Rx Endpoint• To what clinical endpoint would you To what clinical endpoint would you

treat this patient?treat this patient?

• How?How?

• Why?Why?

Case 4: AMS/ComaCase 4: AMS/Coma• A 49 year old male patient with a history of A 49 year old male patient with a history of

hypertension presents to the Emergency hypertension presents to the Emergency Department with a thunderclap headache, Department with a thunderclap headache, vomiting, and altered mental status. Upon vomiting, and altered mental status. Upon arrival to the ED, he becomes unresponsive.arrival to the ED, he becomes unresponsive.

• His vital signs are BP 264/142, HR 90, RR 12, His vital signs are BP 264/142, HR 90, RR 12, and Temp 98.4.and Temp 98.4.

Q: How would you Rx this pt?Q: How would you Rx this pt?• What type of anti-hypertensive agent What type of anti-hypertensive agent

would you use?would you use?

• 1. Oral1. Oral

• 2. IV bolus2. IV bolus

• 3. Continuous infusion3. Continuous infusion

• 4. Other4. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV bolus agent might you use?What IV bolus agent might you use?

• 1. Hydralazine1. Hydralazine

• 2. Labetalol2. Labetalol

• 3. Enalaprilat3. Enalaprilat

• 4. Phentolamine4. Phentolamine

• 5. Other5. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV infusion Rx might you use?What IV infusion Rx might you use?

• 1. Sodium nitroprusside1. Sodium nitroprusside

• 2. Nicardipine2. Nicardipine

• 3. Fenoldopam3. Fenoldopam

• 4. NTG4. NTG

• 5. Esmolol5. Esmolol

• 6. Clevidipine6. Clevidipine

Q: Clinical Rx EndpointQ: Clinical Rx Endpoint• To what clinical endpoint would you To what clinical endpoint would you

treat this patient?treat this patient?

• How?How?

• Why?Why?

Case 5: Ankle PainCase 5: Ankle Pain• A 44 year old male patient with no A 44 year old male patient with no

significant past medical history significant past medical history presents to the Emergency Department presents to the Emergency Department with acute ankle injury while getting off with acute ankle injury while getting off the bus. Exam shows significant soft the bus. Exam shows significant soft tissue swelling to lateral malleolus.tissue swelling to lateral malleolus.

• His vital signs are BP 197/126, HR 89, His vital signs are BP 197/126, HR 89, RR 16, and Temp 98.4. RR 16, and Temp 98.4.

Q: How would you Rx this pt?Q: How would you Rx this pt?• What type of anti-hypertensive agent What type of anti-hypertensive agent

would you use?would you use?

• 1. Oral1. Oral

• 2. IV bolus2. IV bolus

• 3. Continuous infusion3. Continuous infusion

• 4. Other4. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV bolus agent might you use?What IV bolus agent might you use?

• 1. Hydralazine1. Hydralazine

• 2. Labetalol2. Labetalol

• 3. Enalaprilat3. Enalaprilat

• 4. Phentolamine4. Phentolamine

• 5. Other5. Other

Q: What IV anti-hypertensive?Q: What IV anti-hypertensive?• What IV infusion Rx might you use?What IV infusion Rx might you use?

• 1. Sodium nitroprusside1. Sodium nitroprusside

• 2. Nicardipine2. Nicardipine

• 3. Fenoldopam3. Fenoldopam

• 4. NTG4. NTG

• 5. Esmolol5. Esmolol

• 6. Clevidipine6. Clevidipine

Q: Clinical Rx EndpointQ: Clinical Rx Endpoint• To what clinical endpoint would you To what clinical endpoint would you

treat this patient?treat this patient?

• How?How?

• Why?Why?

Q: Start on HTN RxQ: Start on HTN Rx• Would you start them on an anti-Would you start them on an anti-

hypertensive medication?hypertensive medication?

• 1. Yes1. Yes

• 2. No2. No

Q: DispositionQ: Disposition• What special instruction would you What special instruction would you

give for follow-up?give for follow-up?

• Where?Where?

• When?When?

Q: ACEP GuidelineQ: ACEP Guideline• Have you read the ACEP HTN Have you read the ACEP HTN

guideline ?guideline ?

• 1. Yes1. Yes

• 2. No2. No

Q: Any HTN GuidelineQ: Any HTN Guideline• Have you read any HTN guideline ?Have you read any HTN guideline ?

• 1. Yes1. Yes

• 2. No2. No

ConclusionsConclusions• There are good Rx options

• Treatment options must be individualized for each patient

• Guidelines, clinical studies, and literature do provide guidance

• Treat the patient, be careful

• A reasonable standard of care

• Pt outcomes can be optimized

Questions?Questions?edsloan@uic.edu312 317 4996

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