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.
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.
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.
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.
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.