Hypertensive Crisis

Hypertensive CrisisCLINICAL SIGNS:

* sudden rise in blood pressure.

* take and resume the tension after a rest, with a suitable cuff, quiet, lying down for 20 minutes.

– beware:

 False hypertensive crises reactive to any stress such as epistaxis.

 a “white-coat” effect, pain or anguish.

* hypertensive urgency:

– diastolic> 130 mmHg , systolic> 230 mmHg.

– hypertensive encephalopathy:

 intense headaches, visual disturbances, disturbances of vigilance evolving towards confusional syndrome, Babinski +, sometimes coma and seizures.

 digestive disorders: nausea, vomiting.

– look for signs of left ventricular failure (PAD) or ischemic heart disease, eclampsia, stroke.

* hypertensive thrust:

– no sign of visceral pain but risk of aggravation of certain cardiovascular or neurovascular pathologies.

DIFFERENTIAL DIAGNOSIS:

* false hypertension of the elderly subject by incompressibility of the arterial wall by mediacalcosis.

* if hypertensive encephalopathy:

– meningeal hemorrhage.

– stroke.

– intracranial hypertension.

ETIOLOGY:

* essential malignant hypertension.

* abrupt cessation of antihypertensive treatment (Catapressan in particular).

* taking sympathomimetics, alcohol, tricyclics, NSAIDs, toxic (cocaine, crack, …), corticosteroids.

* coarctation of the aorta, stenosis of the renal artery.

* eclampsia.

* during IDM, aortic dissection, acute glomerulonephritis, PAO, stroke: but cause or consequence?

* pheochromocytoma:

– palpitations + sweat attacks + hypertensive attacks + headaches.

– elevation of urine cathecolamines> 300 μg / 24 h.

– do abdominal CT scan, MIBG scintigraphy.

DIAGNOSTIC TESTS:

* if hypertensive pressure:

– no.

* if hypertensive urgency:

– scope, SpO².

 ECG: Left ventricular hypertrophy, repolarization disorders, signs of ischemia.

– urine strips: proteinuria, hematuria.

– fundus: stage II or III (edema + exudates + haemorrhages).

– blood ionogram (hypokalemia?), Serum creatinine, NFS, blood glucose.

TREATMENT:

* to calm the pain and the anxiety.

* if asymptomatic hypertensive pressure:

– no treatment most often.

* if HTA and cerebral pain:

– do not lower blood pressure unless it is very severe.

* if HTA and aortic dissection or eclampsia:

– lower blood pressure to around 120 mmHg.

* in other cases:

– gradually lower the blood pressure (25% of their initial values) because of the risk of cerebral ischemia.

* according to the pathological context and the place of care:

– oral:

 Loxen 20: 2 oral tablets.

 or sublingual Lopril: 25 mg to repeat if necessary, 12.5 mg if elderly person.

 or Trandate: 1 to 2 tablets.

– venous route:

 G5%, oxygen therapy in the mask.

 Lasilix: 2 vials of 20 mg IV if pulmonary edema or renal failure (1-2 mg / kg in children).

 or Lénitral: 1 mg IV slow then 0.5-1 mg / h to the electric syringe if coronary insufficiency, cardiac insufficiency or aortic dissection.

 or Eupressyl: 25 mg IV direct to be renewed optionally 1 or 2 times every 5 minutes then 10-30 mg / h by electric syringe (0.8 mg / kg / h in children) whatever the indication.

 or Loxen: 1-2.5 mg IV direct to be renewed 10 minutes later or infusion of 5 mg in 30 minutes, then 1-4 mg / h in maintenance with the electric syringe (1 to 4 μg / kg / min at the child) regardless of the indication except coronary insufficiency.

 or Trandate: 20 mg IV slow then 0.1 mg / kg / h if eclampsia, if pheochromocytoma, aortic dissection or intoxication.

 if failure:

 Sodium nitroprusside (Nipride) to the electric syringe by the resuscitator.

* hospitalization:

– if brain, heart or kidney lesions or any other visceral repercussions associated.

– if medical treatment fails.

– if child or pregnant woman.

– if patient on anticoagulant.

– if fundamentally at stage III.

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