A comparative study of intravenous labetalol VS intravenous nitroglycerin in the treatment of hypertensive crises

Hypertensive crises is still a major public health problem, causing end organ damage like myocardial infarction, stroke, and renal failure. Labetalol and nitroglycerine are among the two most commonly used medicine to control the blood pressure, but there is no head to head comparison between these two medicines. This was a prospective randomized non-blinded study which included 50 patients of hypertensive crises, out which 25 patients received intravenous labetalol and 25 patients received intravenous nitroglycerine. We found that labetalol controlled the blood pressure more rapidly in comparison to nitroglycerine, without causing any extra side effect

Influencing factors associated with delayed time in pre-hospital emergency medical care for hypertensive emergency in the main urban area of Chongqing / 上海预防医学

ObjectiveTo investigate the influencing factors associated with delayed time in pre-hospital emergency medical care in patients with hypertensive emergency in the main urban area of Chongqing. MethodsA total of 1 246 patients with hypertension in the main urban area of Chongqing from March 2018 to August 2021 were included in this study. The delayed time in the pre-hospital emergency medical care was determined. A multivariate linear regression model was used to analyze the influencing factors. ResultsThe delayed time in the pre-hospital emergency medical care for the patients with hypertensive emergency was concentrated in 0‒12 h， with the average of （5.89±1.96） h. The delayed time differed significantly by gender， age， history of atrial fibrillation， diabetes， educational level， time of onset， mode of transportation， awareness of hypertensive emergency， blood pressure at the onset， and presence of persons at the onset of emergency （P<0.05）. Multivariate linear regression analysis showed that educational level， time of onset， blood pressure at the onset， awareness of hypertensive emergency， presence of persons at the onset were linearly correlated with delayed time in the pre-hospital medical care for hypertensive emergencies （P<0.05）. ConclusionDelay in pre-hospital medical care is prevalent for patients with hypertensive emergency in the main urban area of Chongqing. The delayed time is associated with multiple factors， such as educational level， time of onset， blood pressure at onset， awareness of hypertensive emergency， and presence of persons at onset. It warrants further improvement in the interventions to reduce the delay in the pre-hospital medical care.

Emergencias hipertensivas neurológicas Aproximación diagnóstica y terapéutica con base en imágenes por resonancia magnética / Hypertensive neurological emergencies Diagnostic approach and treatment based on magnetic resonance imaging

RESUMEN El diagnóstico y el tratamiento de las complicaciones cerebrales de la emergencia hipertensiva constituyen un reto para los médicos de urgencias y terapia intensiva. Mediante una aproximación diagnóstica basada en las diferentes secuencias de las imágenes por resonancia magnética se llega al diagnóstico de encefalopatía hipertensiva, isquemia cerebral, hemorragia intracraneal, hemorragia subaracnoidea aneurismática, síndrome de encefalopatía posterior reversible y a su inmediato tratamiento ajustado a nuestro medio según las últimas guías de práctica clínica de la AHA/ASA (Asociación Americana del Corazón y Asociación Americana de Ataque Cerebrovascular).

SUMMARY The diagnosis and treatment of brain injury in patients with hypertensive emergencies is a challenge for the emergency department and intensive care doctors. The diagnosis of hypertensive encephalopathy, ischemic stroke, intracranial hemorrhage, aneurysmal subarachnoid hemorrhage and posterior reversible encephalopathy syndrome is achieved with different MRI sequences as well as their appropriate treatment according to the last AHA/ASA clinical practice guidelines.

Paroxysmal hypertension with reversible posterior leukoencephalopathy syndrome in a child: an unresolved riddle

Nine year old girl was presented with paroxysmal episodes of hypertensive emergency. She was asymptomatic with normal blood pressure without antihypertensives in between the episodes. MRI brain was suggestive of reversible posterior leukoencephalopathy.' Acute episodes were managed with IV labetalol infusion and amlodipine. She was evaluated extensively to find out the etiology of hypertension. Cardiac and renal causes were ruled out. Work up for pheochromocytoma, hyperaldosteronism, porphyria and vasculitis were negative. The case is reported in view of the rare presentation and the leukoencephalopathy noted in this case.

Hipertensão arterial e emergências hipertensivas / Hypertension and hypertensive emergencies

A crise hipertensiva é uma situação clínica comum, caracterizada pelo aumento acentuado e sintomático da pressão arterial, sendo subdividida em emergência e urgência hipertensiva. A emergência hipertensiva difere da urgência hipertensiva por apresentar um risco de morte iminente devido à lesão aguda ou em desenvolvimento nos órgãos-alvo, especialmente coração, cérebro, rins e artérias. Emergência hipertensiva requer uma abordagem clínica que avalie o órgão-alvo comprometido. A intervenção terapêutica deve ser imediata, eficiente e individualizada para cada sistema envolvido, em geral com fármacos anti- -hipertensivos por via endovenosa em unidade de terapia intensiva. Por outro lado, o paciente com urgência hipertensiva não apresenta lesão aguda em órgão-alvo e, portanto, não apresenta risco de morte. Sendo assim, o tratamento anti-hipertensivo pode ser realizado com medicamentos orais na sala de urgência. Este artigo revisa as principais situações clínicas relacionadas à emergência hipertensiva, sua apresentação clínico-epidemiológica, bem como sua abordagem clínica e terapêutica.

Hypertensive crisis is a common clinical situation characterized by a marked and symptomatic increase in blood pressure, being subdivided into emergency and hypertensive urgency. Hypertensive emergency presents an imminent risk of death due to acute or developing in target organs lesions, especially the heart, brain, kidneys and arteries. Hypertensive emergency requires a clinical approach that evaluates the compromised target organ. Therapeutic intervention should be immediate, efficient and individualized for each system involved, usually with intravenous antihypertensive drugs in the intensive care unit. On the other hand, the patient with hypertensive urgency does not present acute target organ injury and, therefore, has no risk of death. Thus, antihypertensive treatment can be performed with oral medications in the emergency room. This article reviews the main clinical situations related to hypertensive emergency, its clinical and epidemiological presentation, as well as its clinical and therapeutic approach.

Clinical features and therapy experience of hypertensive emergency in children / 中国小儿急救医学

Objective To summarize the clinic features and therapy experience of hypertensive emergency(HE) in children.Methods From January 2007 to January 2017,13 children diagnosed as HE were enrolled in Capital Institute of Pediatrics.We summarized the etiology,clinical features,blood pressure levels,laboratory examinations and treatment of these patients with HE retrospectively.Results There were 289 hypertensive patients,while 13 patients fulfilled diagnostic criteria of HE with the rate of 4.5 ％.All patients were secondary hypertension,especially 9 cases were associated with renal diseases.Seven patients with HE accepted intravenous drugs to reduce high blood pressure,while 5 patients with sodium nitroprusside and 2 patients with phentolamine.At the same time,2 to 4 kinds of oral drugs were administrated together with intravenous ones.Two patients died with multiple organ dysfunctions,and one patient gave up treatment and discharged.Other patients improved and discharged.Conclusion Generally,secondary hypertension is the most common reason of HE,especially renal disease,so close monitoring is very important.Hypokalemia is common in patients with HE.Based on effective blood pressure control,treasures for organ and tissue perfusion and protection are very important in patients with HE.

Clinical study of hypertensive crisis at a tertiary care hospital of South India

Background: Hypertensive crisis is a severe clinical condition in which sudden increase in arterial blood pressure can lead to acute vascular damage of vital organs. So timely detection, evaluation and adequate treatment are crucial to prevent permanent damage to vital organs. The aim of the present study is to evaluate incidence and clinical presentation of hypertensive crisis in relation to age, sex, severity of hypertension, accompanying symptoms and clinical manifestations.Methods: It is a clinical prospective study done during the period between January to June 2018 at Narayana Medical College, Nellore. All patients who were more than 18 years with blood pressure>180/120 mmHg to the emergency, outpatients, and inpatients were included. A thorough History and clinical examination was done and necessary investigation was sent to the laboratory.Results: The study results indicate that males (64%) were significantly over represented compared to females (36%). Out of 50 patients majority of the subjects belonged to age group of 50-59 years. Out of 50 Patients most common symptom is Headache (48%), Vomiting (48%), Giddiness (38%), Dyspnoea (22%), Loss of consciousness (22%) followed by chest pain (20%), Blurring of vision (20%) and weakness of limbs (14%). Most of the individuals are in the hypertensive emergency (66%) followed by Hypertensive urgency (34%). Out of 50 patients 56% had neurological involvement and 44% had cardiological involvement. Our study states that most of cases were in grade 1retinopathy (8%) followed in order by grade 4 retinopathy (8%), grade 2 retinopathy (6%) and grade 3 retinopathy (6%).Conclusions: The present study concludes that majority of patients present presenting in hypertensive emergency belonged to fifth and sixth decades of age. So, treating physician should rapidly assess the differentiation of hypertensive emergency and hypertensive urgency in order to prevent end organ damage and to prevent further morbidity and mortality.

¿Podemos comenzar a cambiar nuestra "mirada" ante la urgencia hipertensiva? / Can we start changing our viewpoint towards hypertensive urgency?

La urgencia hipertensiva (UH) es una situación muy frecuente que asusta tanto a los pacientes como a sus familiares y al personal de salud y representa aproximadamente el 30% de las consultas no programadas (o de urgencia). En el presente artículo, los autores se hacen eco de publicaciones recientes y proponen dejar de utilizar el término urgencia hipertensiva para describir las situaciones de elevación de la presión arterial por encima de una tensión arterial sistólica ≥ 180 mmHg y/o una tensión arterial diastólica (TAD) ≥ 110 mmHg, sin asociación con daño de órgano blanco (con o sin sintomatología inespecífica concurrente), ya que los pacientes con este cuadro no corren riesgo inminente, no requieren atención médica de urgencia y, por lo tanto, deberían enmarcarse dentro de los cuidados habituales de los pacientes con factores de riesgo cardiovascular y riesgo cardiovascular global elevado. Esto implica no solo un cambio semántico, sino un desafío en el abordaje y manejo de estas situaciones tan frecuentes. (AU)

Hypertensive urgency (UH) is a very frequent clinical situation that scares patients, their families as well as health care provid-ers and represents approximately 30% of the non-scheduled (or urgent) visits. In the present article, taking into account recent publications, the authors propose to stop using the term hypertensive urgency to describe situations of elevated blood pressure above systolic blood pressure ≥ 180 mmHg and / or diastolic blood pressure ( TAD) ≥ 110 mmHg, without end organ dam-age (with or without concurrent non-specific symptomatology), since patients with this condition are not at imminent risk, do not require urgent medical attention and should therefore be framed within usual care of patients with cardiovascular risk factors and high overall cardiovascular risk. This implies not only a semantic change, but a challenge in the approach and management of these frequent situations. (AU)

Manejo anestésico de emergencia hipertensiva perioperatoria secundaria a tumores neuroendocrinos A propósito de un caso / Anesthetic management of hypertensive emergency perioperative secondary neuroendocrine tumors. Report of a case

Resumen Introducción: Los tumores neuroendocrinos son neoplasias secretoras de hormonas, principalmente catecolaminas, que pueden presentarse en cualquier parte del cuerpo. La incidencia del feocromocitoma es de 2 a 8 por millón de personas por año, y el 10% de ellos son tumores extra adrenales. El manejo anestésico se considera un reto para el anestesiólogo, ya que deben tomar en cuenta varios puntos para el control hemodinámico del paciente, así como el manejo multidisciplinario en el periodo pre, trans y posquirúrgico. Caso clínico: Presentamos el caso de un paciente masculino portador de para-ganglioma vesical sometido a resección quirúrgica bajo anestesia general e infusión de isosorbide para control de la emergencia hipertensiva. Conclusiones: Se consideró, en este caso en particular, que el uso de vasodilatadores periféricos fue benéfico para el tratamiento de la emergencia hipertensiva durante el transanestésico. Discusión: El tratamiento de la emergencia hipertensiva reportado en la bibliografía muestra que el uso de fármacos intravenosos como nitroprusiato de sodio, nitroglicerina, labetalol, esmolol, entre otros, son los más indicados. El uso de nitritos es una alternativa viable con descontrol hipertensivo severo.

Abstract Introduction: Neuroendocrine tumors, can be found anywhere on the body. The incidence of pheochromocytoma is 2-8 per million people per year and 10% of these are extra-adrenal tumors. Anesthetic management is considered a challenge for the anesthesiologist, since they are primarily catecholamine secreting tumors, and they must take into account several points for a hemodynamic monitoring of the patient and the multidisciplinary management in the pre, trans and postsurgical period. Case report: We report the case of a male patient carrier of a bladder para-ganglioma who underwent a surgical resection under general anesthesia and an infusion of isosorbide to control a hypertensive emergency. Conclusions: We considered, in this particular case, that the use of peripheral vasodilators was beneficial for the treatment of hypertensive emergency during trans- anesthetic. Discussion: The treatment of hypertensive emergencies reported in the literature shows that the use of intravenous drugs such as sodium nitroprusside, nitroglycerin, labetalol, esmolol, among others, are the most recommended. The use of nitrite is a viable alternative with severe uncontrolled hypertension.

Tratamento da emergência hipertensiva na dissecção aórtica / Treatment of hypertensive emergency in aortic dissection

A dissecção aórtica é a mais letal das emergências cardiovasculares e, portanto, requer diagnóstico preciso imediato e intervenções terapêuticas clínica e intervencionista em regimes de urgência. Os métodos de imagens, como a ecocardiografia e a angiotomografia, são os métodos diagnósticos de escolha e devem ser considerados na suspeita clínica de dissecção aórtica. A hipertensão é o principal fator de risco para a dissecção e, com frequência, o paciente com dissecção aórtica se apresenta com um quadro de emergência hipertensiva que requer terapêutica rigorosa e imediata. O objetivo da terapêutica é o imediato controle da pressão arterial com nitroprussiato de sódio e a redução da frequência cardíaca com betabloqueador endovenoso, reduzindo a pressão de pulso e o stress parietal na aorta e reduzindo o risco de rotura da aorta ou propagação anterógrada ou retrógada da dissecção. Feito o diagnóstico, a dissecção que envolve a aorta ascendente (Tipo A) deve ser tratada cirurgicamente em regime de emergência. Adissecção restrita à aorta descendente (Tipo B) recebe abordagem clínica inicial e, na vigência de complicações como expansão da falsa luz, hemotórax, dor persistente ou isquemia visceral, deve ser tratada invasivamente com o implante endovascular de stents

Aortic dissection is the most lethal cardiovascular emergencies and, therefore, it requires prompt and accurate diagnosis as well as interventional and clinical therapeutic interventions in emergency regimes. Theimaging methods, such as echocardiography and angiotomography, are the diagnostic methods of choice and should be considered in clinical suspicion of aortic dissection. Hypertension is the leading risk factor for dissection and often the patient with aortic dissection presents with a case of hypertensive emergency that requires accurate and immediate therapy. The goal of therapy is the immediate control of blood pressure withsodium nitroprusside and the heart rate reductionwith intravenous beta-blocker, reducing pulse pressure and the parietal stress in the aorta and the risk of aortic rupture or anterograde or retrograde propagation of dissection. Diagnosed dissection involving the ascending aorta (Type A) should be surgically treated in emergency. The dissection restricted to the descending aorta (Type B) receives initial clinical approach and, in the presence of complications such as expansion of the false lumen, hemothorax, persistent pain or visceral ischemia, it should be treated invasively with endovascular stenting.

Crise hipertensiva / Hypertensive crisis

Crise hipertensiva é uma situação clínica comum, caracterizada por elevação sintomática da pressão arterial. Apresenta alta taxa de morbidade e mortalidade e é classificada como emergência e urgência hipertensiva. O quadro clínico de emergência hipertensiva difere do quadro de urgência por apresentar risco de morte iminente decorrente de lesão em órgãos-alvo instalada ou em evolução, em particular no coração, cérebro, rins e artérias. Essa condição requer uma abordagem clínica criteriosa, que permita o diagnóstico rápido e correto do órgão-alvo envolvido.

Hypertensive crisis is a common clinical situation characterized by symptomatic rise of the blood pressure, it presents high rate of morbidity and mortality, and it is classified in hypertensive emergency and urgency. The clinical picture of hypertensive emergency differs from that of hypertensive urgency by presenting an imminent death risk due to established or developing damage in target-organs, especially heart, brain, kidneys and arteries. This condition requires a sensible clinical approach that allows a correct and fast diagnosis of the compromised target-organ.

Abordagem das emergências hipertensivas / Approach of the hypertensive emergencies

As emergências hipertensivas são situações clínicas de extrema gravidade que são observadas com frequência na prática clínica em pronto atendimento ou unidades de terapia intensiva. O reconhecimento das principais emergências hipertensivas, que incluem edema agudo dos pulmões, síndrome coronária aguda, encefalopatia hipertensiva, acidente vascular cerebral e dissecção de aorta, entre outras, é de extrema importância para uma abordagem terapêutica mais adequada e redução da morbidade e mortalidade associadas. História e exame físico bem orientados para os principais órgãos-alvo da hipertensão, seguidos de exames complementares específi cos, auxiliam para um diagnóstico correto e um tratamento mais efi caz.

Hypertensive emergencies are extremely severe clinical situations frequently observed in clinical practice in intensive care unit or emergency room. The knowledge of main hypertensive emergencies, including acute pulmonary edema, acute coronary syndrome, hypertensive encephalopathy, cerebral vascular accident and aortic dissection, among others, is extremely important for a more adequate therapeutic approach and for a reduction in associated morbidity and mortality. History and physical examination well directed to the main target organ of hypertension, followed by complementary specifi c exams, are helpful for a correct diagnosis and effective treatment.

The Comparison of Antihypertensive Effects among Hydralazine, Clonidine and Nifedipine in Hypertensive Emergency

If hypertensive emergencies are left untreated, multiple damages on heart, brain and kindney can develop. So rapid control of blood pressure within safty with effective antihypertensive agents is mandatory. For the comparison of antihypertensive effects among hydralazine (IV or IM), clonidine (IV), and nifedipine (sublingual) in hypertensive emergency, which were frequently used in our hospital, we performed propective study with hypertensive emergency patients(243 cases) who visited emergency room from Oct. 1986 until Aug. 1987. The results are as follows ; 1) For 58 patients who recieved hydralazine (IV or IM), initial mean arterial blood pressure(MAP) was 167.2+/-21.5mmHg and 15 minutes later 138.9+/-24.4mmHg, 45 minutes later 141.7+/-21.1mmHg, 90 minutes later, 133.9+/-26.6mmHg and, respectively. For 55patients who recived clonidine(IV), initial MAP was 164+/-21.9mmHg and 15minytes later 137.4+/-18.9mmHg, 45 minutes later 127.5+/-34.9mmHg, respectively. For 130 patients who recived nifedipine(sublingual), initial MAP was 159.8+/-21.4mmHg and 15 minutes later 143.0+/-22.8mmHg, 45 minutes later 127.5+/-21.1mmHg, 90 minutes later 119.3+/-20.0mmHg, respectibely. 2) Pulse rate showed 12.9% increase afer administration of hydralazine, 15.8% decrease in clonidine, 5.6% increase in nifedipine, respectively. 3)Severe reduction of blood pressure(systolic BP<130mmHG) after administration of following antihypertensive agents was found. i.e., hydralazine 5.2%, clonidine 1.8%, nifedipine 1.5%, respectively. 4) In 4 cases(6.9%) out of the 58 cases using hydralazine, 3 cases(5.5%) out of the 55 cases using clonidine, 9 cases(6.9%) out of the 130 cases using nifedipine, acute paradoxic hyertensive effects were observed.