【高血压精品英文课件】高血压急症 hypertensive emergencies

HypertensiveEmergencies AmyStaples MD MPHUNMDepartmentofPediatrics Outline MeasuringBPDefinitionofHypertensionEtiologyofhypertensioninkidsWhentotreatHowtotreat ClinicalQuiz 11yogirlwithasinusitis HAandBP124 835yoboywithrash abdpain jointpain teacoloredurineandBP117 8116yoathleticboyinclinicforsportsPEBP132 84 HTNTreat ClinicalQuiz 3yogirlwithNF alertandplayful BP125 772yogirlwithnephroticsyndromeadmittedforalbumin lasixduetoanarsca withsevereHAandseizure BP119 76 onadmit93 52 HTNTreat Outline MeasuringBPDefinitionofHypertensionEtiologyofhypertensioninkidsWhentotreatHowtotreat MeasuringaccurateBP s Cufftoosmall highreadingCufftoobig OKreadingornoreading usuallynotfalselylow Lowerextremities Normally BPis10to20mmHghigherinthelegsthanthearmsPreferarmifatallpossibleRightarmforcomparisonwithstandards CuffSize Bladderwidth 40 ofmid armcircumference Bladderlength80 100 ofarmcircumference A IdealarmcircumferenceB RangeofacceptablearmcircumferencesC BladderlengthD MidlineofbladderE BladderwidthF Cuffwidth OscillometricDevices Measuremeanarterialpressure MAP andcalculatesSBPandDBPThealgorithmsusedareproprietaryandNOTstandardizedResultscanvarywidelyandtheydonotalwayscloselymatchBPvaluesobtainedbyauscultationThesemachinesmustbecalibratedregularly Manualvs Automatic ManualisthegoldstandardOscillometricmeasurementspreferredininfantsandICUsettingsONLYAllhighreadingsshouldbeconfirmedwithamanual ConfirmingHighBP s RepeatBPinbotharmsandoneleg bothnotusuallynecessary Repeat3timestoassureaccurateDxofHTNrequireselevatedBP son3separateoccasions Disappearanceof HTN withRepeatedMeasurement Outline MeasuringBPDefinitionofHypertensionEtiologyofhypertensioninkidsWhentotreatHowtotreat NewBPNormals 4threportonthediagnosis evaluationandtreatmentofhighbloodpressureinchildrenandadolescentsCorrelateswiththeJNC7UsesnewgrowthparameterdatafromNHANES Definitions NormotensiveAverageSBPandDBP90thbut120 80 HypertensionAverageSBPand orDBP 95thpercentileforage sexandheighton3separateoccasionsStage1 95th 99thpercentile 5mmHgStage2 99thpercentile 5mmHg Howtousethetables Need Age gender heightpercentageBPcharts 7yoboyHt75 tile http www cc nih gov ccc pedweb pedsstaff bptable1 PDF 50 99 5890 113 7395 119 8099 127 88 BPtablesforInfants TaskForceonBloodPressureControlinChildren ReportoftheSecondTaskForceonBloodPressureControlinChildren 1987 Pediatrics 1987 79 1 25 PR Urgencyvs Emergency Urgency severelyelevatedBPwithnocurrentevidenceofsecondaryorgandamage althoughifleftuntreated targetorganinjurymayresultimminently DecreaseBPSoonEmergency severelyelevatedBPwithevidenceoftargetorganinjury DecreaseBPImmediatelyTargetorgans CNS heart kidney eye ConstantineandLinakis PediatricEmergencyCare 2005 SevereHypertension Hypertensionthatrepresentsathreattolifeortothefunctionofvitalorgans ORSeverehypertensioniswhenyourbloodpressuregoesuptoo Adelman etal PediatricNephrology 2000 Outline MeasuringBPDefinitionofHypertensionEtiologyofhypertensioninkidsWhentotreatHowtotreat EtiologyofHypertension ConstantineandLinakis PediatricEmergencyCare 2005 MiscellaneousCauses EndocrineHyperthyroidPheochromocytomaElevatedICP CNSdiseaseDruguse cocaine ecstasy Medication abruptwithdrawal ExerciseTractionHypovolemia Overall 15 20 EssentialHypertension80 85 SecondaryHypertension60 80 Renal8 10 Renovascular2 Coarctation Outline MeasuringBPDefinitionofHypertensionEtiologyofhypertensioninkidsWhentotreatHowtotreat Whichhypertensivepatientsneedimmediatetreatment SevereHTNMalignantHTN 30 above95 Moderate SevereHTN 99 withtargetorgandamageSymptomaticHTNTargetOrganDamage ComplicationsofSevereHTN Retinopathy27 Encephalopathy25 LVH13 Facialpalsy12 Visualchanges9 Hemiplegia8 Deal etal ArchDisChild 1992 ClinicalSignsofMalignantHTN EyesRetinalhemorrhages exudatesandpapilledemaMalignantNephrosclerosisARF Hematuria ProteinuriaHypertensiveEncephalopathyHeadache nausea vomitingRestlessness confusion seizures comaMRI T2 weightedimages Edemaofthewhitematteroftheparieto occipitalregions posteriorleukoencephalopathy Eyes Papilledema blurredopticdisk hemorrhages HypertensiveEncephalopathy Failureofautoregulation Flynn PedNeph2009 24 1101 1112 Shiftedbaseline HypertensiveEncephalopathy Headache nausea vomitingRestlessness confusion seizures comaPosteriorLeukoencephalopathy PosteriorLeukoencephalopathy T1weightedimages normalappearingT2weightedimages occipitalhyperintensity Outline MeasuringBPDefinitionofHypertensionEtiologyofhypertensioninkidsWhentotreatHowtotreat SevereHypertension TreatmentGoalsPreventadverseeventsReduceBPincontrolledmannerPreservetargetorganfunctionMinimizecomplicationsoftherapy SevereHypertension TreatmentRisksRapidreductionofBPcanleadtocomplicationsRiskofhypoperfusion ischemia secondarytoautoregulationMedicationsideeffectsmayhaveadverseeffectsdependingoncauseofhypertension e g ACEi HowMuch JustEnoughDependsonAcutevs Chronic HowMuch Reduceby25 oftheplannedreductionover8 12hrsAnother25 overthenext8 12hrsFinal50 overthenext24hrsPlannedreduction goalistothe95 99 forageandheightIfUnsure slowerissafer Whattodo1st Monitor Monitor MonitorNeedcardiopulmonarymonitoringNeedcontinualBPmonitoring frequentlycyclingcuffvs arterialline Decideoralvs IVOralOKifasymptomaticIVnecessaryifacutetargetorgandamageispresentorimminent Oralvs IV IVMedicationRapidActionTitratableEasytoadjustthedoseRequiresIVaccess POMedicationDon tneedanIVHardertocontroleffectsAbsorptionvariableSlowerkineticscanmaketitratingmoredifficult Whattochoose FirstLinePOIsradipineNifedipineIVNicardipineNitroprussideLabetalol SecondLinePOClonidineIVHydralazineEnalaprilatFenoldopam Isradipine Cachannelblocker InhibitCa entryintosmoothmusclecells vasodilitation Onsetofaction30 60minutesSideEffects peripherialedema flushing nausea headache tachycardia0 05 0 1mg kg doseq4 6hrs2 5mgand5mgtab 1mg 1mlsuspensionNifedipine 0 1 0 25mg kgq4 6hours 10mgtabavailable Onsetofaction15 30min AnoteonShortactingCaChannelBlockers InadultswithsevereelevationsinBP Nifedipinehasbeenassociatedwith CerebralischemiaMyocardialischemiaSymptomatichypotensionPreexistingMI CAD andhypovolemiapredisposetotheseevents InchildrenNifedipine Isradapinehavenotbeenassociatedwithcerebralormyocardialevents GrossmanE JAMA1996 276 1328 31 SinaikoAR NEJM1997 336 1675 Nicardipine CachannelblockerOnsetofactionwithinminutesSideEffects sameasisradipine1 3mcg kg mincontinuousinfusion Nitroprusside Directarteriolar venousdilator vianitricoxidedonation OnsetofactionwithinsecondsSideEffects cyanide thiocyanatetoxicity0 5 1mcg kg mininitially titratetomax10mcg kg minMustmonitorcyanidelevelsifusedfor 24hrs Labetalol Mixedalpha betablockerOnsetofaction5 10minSideEffects bronchospasm contraindicatedinasthma cardiogenicshock pulmonaryedema orheartblock0 2 0 3mg kg doseq10 20min maxdose20mg canbeconvertedintoadrip Enalaprilat ACEinhibitor preventsthevaso constrictiveandNaretainingeffectsoftheRAS Onsetofaction15min longdurationofactionSideEffects riskofdecreasedGFR0 005 0 01mg kg doseUseincasesofseverereninmediatedHTN Hydralazine DirectarteriolarvasodilatorSideEffects maycauseLupus likesyndromeCanbegivenPO IV IM0 1 0 5mg kgq4 6hr max20mg dose Case 1 11yogirlwithasinusitis HAandBP124 83Ht75th BloodPressures50 105 6295 122 8099 128 87DiagnosisPain repeatwhenwell notreat