Hypertension: Urgency vs. Emergency

by Carlo Raj, MD

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    00:02 There are two types of hypertensive issues that you want to pay attention to. One is going to be urgency. The other one will be emergency. Please take a look at the differences.

    00:11 Good. Urgency, what does that mean? Well, say that you get a cut. Some mechanical object introduces a cut. You are going to go to an urgicare. But what if you get into a car accident and you are massively hemorrhaging? You are not going to go an urgicare. Where are you going? You are going to the ER, the emergency room. Same concept here, however, I want you to apply to hypertension. Urgency, do you need treatment? Yes, you do, which you have a little bit more time to deal with this. Take a look at the blood pressure where systole of 180 and a diastole of 120. What is normal? 120/80. What is definition of hypertension? 140/90 and above, and we have 180 and 120. But the most important point is the fact that the organs are not affected. Now, what organs might you be thinking about when you have hypertension? You should be thinking about the heart. You should be thinking about the kidney, but notice please that there is no end organ damage. Definition of urgency, hypertension.

    01:19 What about an emergency? You see this list here. So my job is to make sure that all I am doing is reading the list, you know it is your job to memorize it. It is the fact that as you go from head to toe and you have hypertension that is so high, guess what. You are actually causing end organ damage. So begin with the brain. There is enough pressure in which the brain parenchyma is being damaged. What is this called? Good. Encephalopathy. What if it is enough damage that is taking place in the blood vessel leading to the brain? What does that result in? It is not encephalopathy. It is called a stroke. It is called a CVA, what does that mean? Cerebrovascular accident. So what is that patient going to result in? What did I just do? It is the fact that maybe my speech gets impeded maybe there is one side of the body, which doesn't want to move anymore. Some type of stroke like issue maybe it is hemorrhagic, maybe it is ischemic. What kind of hypertension? Emergency, is there an organ being damaged? Of course there is. That is definition of emergency. What do you want to do with immediate treatment? We haven't got into treatment yet, but we shall. Next, you do a fundoscopic examination. What are you checking for? You are checking for the retina. Are you there? Well look at me, but I want you to look into my retina. How are you going to do that? Not with your naked eye, with the fundoscopic examination. What are you going to notice? Papillary edema. Hypertension is quite high. What are you worried about? Emergency hypertension. What do you want to do? Immediate therapy. Let us continue. Well, the heart gets damaged, what is that called? Congestive heart failure, CHF. So what do you want to provide? Advanced cardiac support. Put those together please, ACS, CHF. What is going on? Organ being damaged. What kind of hypertension? Emergency. Urgency? No, high hypertension, but in urgency, the organs remain pretty much intact. Dissection what is happening? I want you to take a hose and I want you to turn up the pressure so high that at some point the hose can’t take it anymore. What is it going to do? It will dissect right through there. What is this hose that I am referring to? In your body, it is called the aorta. And the aorta if there is enough hypertension at some point, what is going to happen? You got to dissect right through. Close your eyes, think of the anatomy. What do we have? Intima, media, adventitia. You might then do what? Dissect right through and when you do so, isn't that emergency? How is that patient going to present you, please? Stabbing back pain, 9/10, 10/10 stabbing back pain. Welcome to dissection. What about the kidney? Is that going to undergo damage? Of course, it will. What is that called? Acute renal failure.

    04:00 Patient will get ARF. If there is enough kidney damage, what may then happen? You might release RBCs, which is called hematuria clinically. Finally, we have enough damages taking place in your blood vessels. What may then happen to the RBC as it traverses through the blood vessel? It might get damaged. What is that called? Microangiopathic hemolytic anemia, MAHA. Is that clear? Now earlier I said that we will have a little bit more time with urgency. Pay attention to reducing blood pressure is being an objective in both. Clear? So that is the general concept. But then hours and days, if it is urgency, "a quite reduction." Emergency, this is not a joke. 25 reduction blood pressure, you want to do this over minutes and hours. What was the definition of emergency? What happened? It is the fact that your organs were damaged. What kind of organs were they? They were the brain, what's that called? Encephalopathy. Papilledema. What if it was the heart? It is called congestive heart failure. What about the kidney? Chronic renal failure, so on and so forth. What about the agents that you might want to use here in terms of emergency? You do everything to make sure the blood pressure drops ASAP. So welcome to nitroglycerin, NTG. Nitroglycerin, what does that mean to you in pharmocology? It means that you are going to have universal vasodilation. Why do I say universal? Because you should know that the veins are undergoing vasodilation. The veins are underdoing vasodilation, what does that mean? Less blood that is being delivered to the heart. What does that mean, please? In physiology, you have heard of preload.

    05:32 You decreased your preload, do you not? Of course, you do. When you do exactly what? Provide nitroglycerin. What else may happen? What is the hypertension? You want to, therefore, decrease the resistance. What about the arteriole side? Would nitroglycerin do that as well? Of course, it does. So what does that due to afterload? Also decreases it. In the process, what are you doing to your blood pressure? A decreases. Welcome to emergency. How much time, minutes, hours? Understand the concept first. It is the fact that in both urgency and emergency, the hypertension is quite high. But it is the fact that well is the organ being affected is to know.

    About the Lecture

    The lecture Hypertension: Urgency vs. Emergency by Carlo Raj, MD is from the course Hypertension.

    Included Quiz Questions

    1. Blood pressure of 200/100 mm Hg in a patient with hematuria
    2. Blood pressure of 190/120 mm Hg in a patient with no other symptoms
    3. Blood pressure of 150/100 mm Hg in a patient with a urinary tract infection
    4. Blood pressure of 140/90 mm Hg in a patient with papilledema
    5. Blood pressure of 180/100 mm Hg in a patient with COPD
    1. Lower blood pressure by no more than 25% over several minutes using IV nitroprusside
    2. Lower blood pressure to 140/90 mm Hg immediately with sublingual nitroglycerin
    3. Lower blood pressure by at LEAST 25% over several minutes using sublingual nitroglycerin
    4. Lower blood pressure to 140/90 mm Hg immediately with oral hydrochlorothiazide
    5. Lower blood pressure by no more than 25% slowly over several minutes using oral metoprolol tablets
    1. Reduce blood pressure over hours-days using oral medications
    2. Reduce blood pressure over hours-days using IV medications
    3. Reduce blood pressure immediately using IV medications
    4. Reduce blood pressure over hours-days using diet and exercise
    5. Reduce blood pressure in min-hrs using oral medications
    1. Highly elevated blood pressure with no end organ damage
    2. Highly elevated blood pressure with papilledema
    3. Highly elevated blood pressure with congestive heart failure
    4. Highly elevated blood pressure with encephalopathy
    5. Highly elevated blood pressure with ischemic cerebrovascular accident

    Author of lecture Hypertension: Urgency vs. Emergency

     Carlo Raj, MD

    Carlo Raj, MD

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    By Estee W. on 14. October 2018 for Hypertension: Urgency vs. Emergency

    Lecturer can't seem to deliver a coherent sentence, jumps around in his delivery. Did not make clear that in emergency situation reduction in BP should be no more than 25%.