Download - Hipertensi Emergensi Dx and Rx (Ws)
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Hypertensive Emergencies:
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Tips for Having your blood
pressure taken.• Don’t drink coffee or smoke cigarettes for
30 minutes before.
• efore test sit for five minutes !it" backsupported and feet flat on t"e ground.
Test your arm on a table even !it" your
"eart.• #ear s"ort sleeves so your arm is
e$posed.
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Tips for "aving blood pressure
taken.• %o to t"e bat"room before test. & full
bladder can affect bp reading.
• %et ' readings and average t"e t!o of
t"em.
• &sk t"e Dr. or nurse to tell you t"e result
in numbers.
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Size Name Cuff Size Bladder Circumference
Small Adult size 22–26 cm 12–24 cm
Adult (regular or standard size) 27–34 cm 16–30 cm
Large Adult size 34–44 cm 16–36 cm
Thigh size 4–2 cm 20–42 cm
Four sized cuffs (minimum adult and large adult cuffs
in room) small adult and t"ig" *uickly available+.
,efer to t"e listed measurements for cuff and bladder.
Note: Manufacturers may have different names for their
various sized cuffs.
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!om"orta#le room tem$erature !old can cause $eri$heral %asoconstriction and decreasing
#lood "lo&' &hich can cause a "alse lo& reading
Table and chair: Ta#le at a height so that the clients
u$$er arm is su$$orted and the #rachial arter* is le%el
&ith heart
!hair arm rests are too lo&
+ ," arm is too lo&- "alse high
+ ," arm is too high- "alse lo&
Procedure Rationale
Wall mount sphygmomanometer:
.osition the monitor at screener e*e le%el and &ithin one
meter "rom the screener
+ Sta*s in cali#ration longer and cant #e dro$$ed
+ /*e le%el in order to mae accurate reading
Cuff size: our cu"" sizes should ideall* #e a%aila#le At
minimum' an adult and large adult cu"" should #e
a%aila#leCuff size with arm and bladder circumferences:
+ Small Adult- 2226 cm' 1224 cm
+ Adult (standard)- 2734 cm' 1630 cm
+ Large adult- 3444 cm' 1636 cm
+ Thigh- 42 cm' 2042 cm
The most common error in #lood $ressure measurement is
the use o" an ina$$ro$riate cu"" size /rrors o%er 30 mmg
can occur i" an undersized cu"" is used+ !u"" #ladder length should #e at least 50 $ercent o" armcircum"erence
+ !u"" #ladder &idth should #e at least 40 $ercent o" armcircum"erence
+ ," cu"" is too small "alse high (more $ressure needed toocclude arter*)
+ ," cu"" too large "alse lo& (less $ressure needed toocclude arter*)
+ ""ice sta"" escorts client to screening area
+ !lient sits 8uietl* "or "i%e minutes #e"ore #lood
$ressure chec &ith legs uncrossed' "eet "lat on the "loor' #ac su$$orted' and u$$er arm #are
+ 9lood $ressure taen &ith legs dangling or unsu$$orted #ac leads to "alsel* high readings (on a%erage "i%e
mmg)+ !rossing the legs ma* increase s*stolic $ressures
As &h* the client is here "or a #lood $ressure chec ,n order to $ro%ide the a$$ro$riate ser%ice "or the client'
as-
+ Are *ou ha%ing s*m$toms:
+ a%e *ou #een instructed #* *our health care $ro%ider toha%e checs:
+ ther 8uestions:
Blood Pressure easurement
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-uff i/e
• ladder width > 40% of
midarm circumference.
• ladder length 80-100%
of arm circumference.
A. Ideal arm circumference
B. ange of acce!ta"le arm
circumferences
#. Bladder length
$. idline of "ladder
&. Bladder width
F. #uff width
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Cause Systolic !ffect
The cu"" is too small (;ost common cause o" error in clinical $ractice
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1scillometric Devices
2easure mean arterial pressure (2&+ and
calculates and D
– The algorithms used are proprietary andNOT standardized
– Results can vary widely and they do not
always closely match BP valuesobtained by auscultation
– These machines must be calibratedregularly
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2anual vs. &utomatic
• 2anual is t"e gold standard
• 1scillometric measurements preferred
in infants and 4-5 settings 1678
• &ll "ig" readings s"ould be confirmed
!it" a manual
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-onfirming Hig" ’s
• ,epeat in bot" arms and one leg
(bot" not usually necessary+
• ,epeat 3 times to assure accurate
• D$ of HT6 re*uires elevated ’s on 3
separate occasions
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Disappearance of 9HT6 !it"
,epeated 2easurement
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• -ase resentations
• Definitions
• Evaluation
• 2anagement
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-ase ;
• '?0@;A'
>Head -T can s"o!ed ,ig"t basal ganglia"emorr"age !it" s"ift
• H4: Transported by air ambulance to E,. > 4ntubated en route due to declining mental status
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-ase ;
• 2H Hypertension according to !ife=
patient !as nonad"erent !it" prescribed
medications > 1ut patient medications and allergies not
available
> Bamily History Cfor HT6@-&
• E$am E, ;?@;30 > ositive for 7eft dense "emiparesis
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-ase ;
• Hospital day '
> Dilated rig"t pupil
> Emergent rig"t frontotemporal craniotomyand evacuation of clot
• ubse*uent Hospital -ourse
> Difficult to control > neumonia
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-ase ;
• ,enal 2,4
> ,ig"t kidney F.; cm !it" t"ree renal
arteries > 7eft kidney ;'.' cm !it" t!o renal arteries
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Guestion ;
• #"at is t"e primary reason for"ypertensive emergencies today
;. ,enovascular Disease'. "eoc"romocytoma
3. 6onad"erence to anti"ypertensivemedication
I. Hyperaldosteronism
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#"at is t"e primary reason for
"ypertensive emergencies today
;. ,enovascular
Disease
'. "eoc"romocytoma
3. 6onad"erence to
anti"ypertensive
medication
I. Hyperaldosteronism
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Hypertensive Emergency
• &ccording to t"e Joint 6ational
-ommittee on Hypertension ,eport
• everely elevated blood pressure !it"signs and symptoms of acute end organ
damage
• Requires hospitalization
• Requires parenteral medication
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Hypertensive 5rgency
• everely elevated blood pressure
without signs and symptoms of acute
end organ damage• -an be managed as an outpatient
• -an be managed with oral medications
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Hypertensive Emergency
• Damage Heart -HB= 24= angina
Kidneys acute kidneyinLury= microscopic
"ematuria
-6 encep"alopat"y=intracranial "emorr"age=
%rade 3I retinopat"y
asculature aortic dissection=
eclampsia
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Epidemiology
• Hypertensive emergencies are common
> 1ccur in ;'M of t"e "ypertensive population
> ut=
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Epidemiology
• -ommon associations
> revious "istory of "ypertension
> 7ack of a primary care p"ysician
> 6on ad"erence to anti"ypertensive
regimen
> Elicit drug use (cocaine+
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at"op"ysiology
udden increase in
ystemic ascular
,esistance
2ec"anical tress !it"
endot"elial inLury= increased
permeability= -oag@lt
activation= fibrin deposition
;+ Bibrinoid necrosis
'+ 4sc"emia
3+ &ctivation of ,&&
I+ roinflammatory
cytokines
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5nderlying Etiology
• 5nclear= but some candidates
> &-E DD genotype
> &bsence of t"e
β
and γ
subunit of E6a-
> Elevated adrenomedullin levelsN
> Elevated natriuretic peptide levelN
> &bnormalities in o$idative stress markers and
endot"elial dysfunctionN > N-orrect after effective treatment
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Guestion '
• #"at is t"e most common complaint in
"ypertensive emergency
;. 6eurologic defect
'. %ross Hematuria
3. -"est painI. Headac"e
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#"at is t"e most common complaint
in "ypertensive emergency
;. 6eurologic defect
'. %ross Hematuria
3. -"est pain
I. Headac"e
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-linical resentation
• ariable
• Oampaglione et al (Hypertension 'A:;II= ;?+
> ;I= '0 E, visits in one year period
> ;0F met definition of "ypertensive
emergency (0.FM+
> 2ean ystolic ';0 C 3' > 2ean Diastolic ;30 C ;<
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-linical resentation
• Bre*uency of signs and symptoms
> -"est ain 'AM
> Dyspnea ''M
> 6euro defect ';M
> 4nterestinglyP.
• Headac"e !as only 3M and epista$is !as 0Min t"is study
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Guestion 3
• Hypertensive emergency is associated
!it" a t"res"old of
;. ystolic Q ''< mm Hg
'. Diastolic Q ;;0 mm Hg
3. ystolic Q '
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Hypertensive emergency is
associated !it" a t"res"old of
;. ystolic Q ''< mm Hg
'. Diastolic Q ;;0 mm Hg
3. ystolic Q '
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T"res"old
• T"ere is no specific !"ere
"ypertensive emergencies occur
• ut= organ dysfunction is rare !it"diastolic s R ;30 mm Hg
> ,ate of increase may be more important
> Hence= encep"alopat"y !ill occur at lo!ers in pregnancy and in c"ildren
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4nitial Evaluation
• Bocused "istory
> History of "ypertension
> Ho! !ell is "ypertension controlled
> #"at anti"ypertensives
> &d"erence to anti"ypertensive regimen
> 7ast dose of anti"ypertensive
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4nitial Evaluation
• ocial History
> ,ecreational Drugs
• &mp"etamines
• -ocaine
• "encyclidine
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4nitial Evaluation
• -onfirm in bot" arms
• 5se appropriate si/ed cuff
• -uff t"at is too small
> cuffs t"at are too small falsely elevate
measurements in obese patients
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4nitial Evaluation
• &ssess for endorgan damage
• ascular Disease
> &ssess pulses in all e$tremities
> &uscultate over renal arteries for bruits
• -ardiopulmonary
> 7isten for rales (-HB+
> 2urmurs or gallops
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4nitial Evaluation
• 6eurologic E$am
> Hypertensive Encep"alopat"y mental
status c"anges= nausea= vomiting= sei/ures > 7aterali/ing signs uncommon and suggest
cerebrovascular accident
• ,etinal E$am > 7ost art
> Keit"#agenerarker -lassification
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Keith-Wagener-Barker Classification
• %rade ;
> 2ild narro!ing of t"e arterioles
> 9-opper #ire
• %rade '
> 2oderate narro!ing
-opper !ire and & nicking
• -"anges associated !it" long standing
essential "ypertension
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6ormal
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%rade ;
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Keith-Wagener-Barker Classification
• %rade 3 > evere 6arro!ing
ilver !ire c"anges= "emorr"age= cotton!ool spots= "ard e$udates
• %rade I > %rade 3 C apilledema
• %rade 3 and I "ig"ly correlated !it"progression to end organ damage anddecreased survival
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%rade 3 K# ,etinopat"y
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7ab Testing
• E-%
> 7H= look for signs of isc"emia= inLury= infarct
• ,enal Bunction Tests (urine included+ > Elevated 56= -reatinine= proteinuria= "ematuria
• --
• -S, pulmonary edema= aortic arc"= cardiac
enlargement
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7ab Testing
• &ortic Dissection
> uspect !it" severe tearing c"est pain=
une*ual pulses= !idened mediastinum > -ontrast -"est -T can or 2,4
• ulmonary Edema@-HB
> Transt"oracic Ec"ocardiogram > Differentiate bet!een systolic dysfunction=
diastolic dysfunction= mitral regurgitation
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2anagement
• Elevated !it"out target organ
damage
• Hypertensive urgency
• 1ral meds
• %oal gradual reduction of over 'I
IF "ours
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2anagement
• Elevated !it" target organ damage
• Hypertensive emergency
• arenteral meds
• %oal ,educe diastolic by ;0;
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Ho! Guickly
• -erebral lood Blo! &utoregulation > -erebral lood constant in normotensive
individuals over range of 2&s of ?0 ;'0
mm Hg. > 4n c"ronically "ypertensive patients
autoregulatory range is "ig"er
> 2& ,ange ;00;'0 to ;
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Ho! Guickly
• %eneral rule is to lo!er 2& by '0M in
first "our
• "ould al!ays be done !it" closeclinical observation
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2anagement
• #"ere
> 4-5 !it" close monitoring
> evere re*uires intraarterial monitoring
• #"ic" arenteral meds
• Depends on t"e situation
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Guestion I
• #"ic" of t"e follo!ing drugs s"ould notbe used to treat "ypertensive
emergency
;. ublingual 6ifedipine
'. 7abetolol
3. &-E 4n"ibitors
I. 6icardipine
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#"ic" of t"e follo!ing drugs s"ould
not be used to treat "ypertensive
emergency
;. ublingual
6ifedipine'. 7abetolol
3. &-E 4n"ibitors
I. 6icardipine
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referred &gents
• eta blockers
> 7abetolol
> Esmolol
• -alcium Entry blocker
> 6icardipine
• Dopamine; receptor agonist
> Benoldapam
• asodilators nitroprusside@nitroglucerin
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cenarios
• 1ur -ase &cute isc"emic
stroke@cerebrovascular bleed
• &gents > Benoldopam
> 7abetolol
> 6icardipine
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-& or 4sc"emic troke
• elevation after -& or isc"emic stroke can
be protective to preserve cerebral perfusion
• Hold on aggressive lo!ering unless > T"rombolytic t"erapy anticipated or
> e$cessively "ig" ( Q ''0 mm Hg or D
Q;'0+
• %oal for t"rombolytic t"erapy is to lo!er if Q ;F< or D Q;;0
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-ardiac -onditions
• &cute ulmonary Edema !it" systolic
dysfunction
> 6icardipine > Benoldopam
> odium nitroprusside
> 6itroglycerin > 7oop diuretic
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-ardiac -onditions
• &cute ulmonary Edema !it" diastolic
dysfunction
> Esmolol= metoprolol= labetolol > verapamil
> 6itroglycerin
> 7oop diuretic
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-ardiac -onditions
• &cute myocardial isc"emia
> Esmolol= labetolol
> 6itroglycerin
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ympat"etic -risis
• %enerally in association !it"
recreational drugs suc" as cocaine=
amp"etamine or p"encyclidine• udden cessation of clonidine or eta
adrenergic antagonist
• "eoc"romocytoma rare
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Guestion <
• #"ic" of t"e follo!ing drugs s"ould beavoided in sympat"etic crises !it"
"ypertensive emergency
;. "entolamine
'. en/odia/epine
3. 7abetolol
I. 6icardipine
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#"ic" of t"e follo!ing drugs s"ould
be avoided in sympat"etic crises !it"
"ypertensive emergency
;. "entolamine
'. en/odia/epine
3. 7abetolol
I. 6icardipine
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ympat"etic -risis
• etaadrenergic antagonists !ill resultin unopposed alp"aadrenergic
stimulation• 4n cocaine use= eta blockers can
> 4ncrease blood pressure
> #orsen coronary artery vasoconstriction
> Decrease survival
• Avoid beta blockade (including nonselective agents such as labetolol
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ympat"etic -risis
• ,ecommended Drugs
> 6icardipine
> Benoldopam > erapamil
> en/odia/epine
> 4f p"eo suspected use p"entolamine
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&ortic Dissection
• Treatment is paramount
> A < year survival is A
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&ortic Dissection
• asodilator alone
> -auses refle$ tac"ycardia
> 4ncreases cardiac eLection velocity > 4ncreases aortic s"ear forces
> E$tends t"e dissection
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&ortic Dissection
• tandard t"erapy
> etaadrenergic blocker plus vasodilator
> Esmolol C 6icardipine or fenoldopam
• 6itroprusside can be used as !ell
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&cute ost 1perative Hypertension
• Bre*uent in postoperative state ('0A 4ncreased stress "ormones
> &ctivation of ,&&
• &lso "ypot"ermia= "ypo$ia= carbondio$ide retention= bladder distention
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&cute ost 1perative Hypertension
• revention > afe to give anti"ypertensives preop
> Hold diuretics• Treatment t"res"olds vary
> -ontrol pain and an$iety
>#"ile 61 use nicardipine= esmolol orlabetolol
> ,esume oral medications !"en possible
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#"at "appened to sodium nitroprusside
• 2ansoor and Briedman. Heart -isease
'00') I:3 odium nitroprusside recommended for all
"ypertensive emergencies e$cepteclampsia
• 2arik and aron. !hest '00A) ;3;:;I
> odium nitroprusside recommended for• acute aortic dissection
• acute pulmonary edema !it" systolic
dysfunction
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9riding t"e pride
• Disadvantages of sodium nitroprusside
> Decrease cerebral blood flo! and increases
intracranial pressure
> -an reduce regional blood flo! in coronary artery
disease
> ,isk of cyanide to$icity
• 5se !"en ot"er agents not effective > 2onitor t"iocyanate levels
> &void in renal or "epatic dysfunction
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Have !e made progress
• Birst described by ol"ard and Ba"r > -ie rightsche "ierenkrankenheit+ /linik
0atholgie und Atlas. erlin= %ermany=pringer ;;I:'IA
• Keit"= #agener= arker Am $ Med 1ci2;3);A:33'
> 2ean survival of patients !it" "tn andgrade I retinopat"y !as ;0.< mo !it" noneliving beyond < years
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#e "ave made progress
• Development of anti"ypertensive drugs
• 4ncreased diagnosis of "ypertension
• 4ncreased 4-5 settings
• urvival of patients !it" "ypertensive
urgency and emergency is ;F years
compared to '; years in t"ose !it"uncomplicated "ypertension
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T"ank you
Guestions
#"en you "ear "oof beats
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#"en you "ear "oof beatsP
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2esserli " #ngl $ Med ;
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