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1 Liter bolus of normal saline
2%
1/58
IV furosemide
50%
29/58
Oral captopril
5%
3/58
IV nicardipine
3%
2/58
IV nicardipine and furosemide
38%
22/58
Select Answer to see Preferred Response
The patient presents with acute shortness of breath, systolic blood pressure > 180 mmHg, and evidence of end-organ damage consistent with hypertensive emergency and acute pulmonary edema. Initial management should include IV nicardipine for his hypertensive emergency, and furosemide with oxygen for his acute pulmonary edema. Hypertensive URGENCY is defined as systolic blood pressure greater than 180 mmHg or diastolic blood pressure greater than 120 mmHg without evidence of end-organ damage. Hypertensive EMERGENCY is an acute increase in blood pressure with evidence of target organ damage. Example organ pathology includes heart failure/pulmonary edema, acute coronary syndrome, neurologic damage/encephalopathy, papilledema, renal failure, and others. Treatment consists of IV anti-hypertensives (i.e. nitroprusside, labetalol, nicardipine, hydralazine, esmolol, etc) to lower mean arterial pressure (MAP) by 25% within about 2 hours. The specific end-organ pathology involved with the hypertensive crisis will dictate which anti-hypertensive is utilized. Sanders reviews hypertensive emergency and notes that quick administration of antihypertensives and careful monitoring are central to treatment. End-organ involvement further tailors the treatment. In general, lowering the MAP by 20-25 percent per hour is appropriate. Cannon et al. compared treatment options in hypertensive crises. When end-organ damage was suspected (ie hypertensive emergency), patients who received nicardipine were more likely to reach target systolic blood pressure at 30minutes than patients who received labetalol. Illustration A shows findings on exam for the various types of hypertensive emergencies. Incorrect Answers: Answer 1: Fluid administration would likely exacerbate this patient’s high blood pressure. Answer 2: Diuresis is necessary to help alleviate this patient's acute pulmonary edema, but IV furosemide alone will not be sufficient to treat this patient's hypertensive emergency. Answer 3: Oral captopril, labetalol, clonidine, and hydralazine are appropriate medications for hypertensive urgency. Answer 4: IV nicardipine will treat this patient's hypertensive emergency, but diuresis is also necessary to treat this patient's acute pulmonary edema.
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