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76 Cards in this Set

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  • Back
Define Hypertensive Crisis
Critical elevation of blood pressure usually SBP >160 and DBP >100
Define Hypertensive URGENCY
HTN crisis w/o acute target organ damage
Define Hypertensive EMERGENCY
HTN crisis with acute target organ dammage
Describe the pathophysiology of hypertensive crisis
The increased BP results in arterial fibrinoid necrosis. Endothelial damage leads to activation of the clotting cascade and release of vasoconstrictor substances.
The RAS system and catecholamine release are triggered.
Pre-existing HTN actually lowers probability of hypertensive emergency through adaptive methanisms.
You also get increased release of cytokines due to mechanical stretching of vessel
Describe Autoregulation
A protective mechanism by which cerebral blood flow maintains a constant cerebral perfusion over a large range of MAP. Chronically hypertensive patients have a right shift in the autoregulatory curve, so that cerebral blood flow is not maintained at low MAP avlues compared to non-hypertensives. Hypertensives require higher MAP to maintain adequate cerebral blood flow.
Describe the Target End-organ damage in hypertensive emergency
1.Hypertensive Encephalopathy
2.Acute aortic dissection
3.Acute pulmonary edema with respiratory failure
4.Acute MI/Unstable angina
6.Acute renal failure
7.Microangiopathic hemolytic anemia
Describe Hypertensive encephalopathy
HA, altered level of consciousness, advanced retinopathy with arteriololar changes, hemorrhage sand exudates.
Papilledema seen on examination of fundi
Describe Acute Aortic Dissection
Dependent not only on elevation of BP but also on velocity of left ventricular ejection
Describe Eclampsia
Visual defects, severe headaches, seizures, cerebrovascular accidents, severe right upper quadrant abdominal pain, congestive heart failure and angina
Describe acute renal failure
Hematuria, proteinuria and increased SCr
Describe Perioperative hypertension
SBP >20% pre operative reading for 15 minutes or >50% increase from original value.
Incidence is 50% depending on surgery
Antihypertensive treatment reduces myocardial ischemia, neurological ischemia, neurologicla deficits and mortality.
Describe Postoperative Hypertension
Generally lasts 2-6 hours post surgery.
Requires rapid control of BP: Control bleeding at suture sites, neurology checks, myocardial ischemia develops due to increased oxygen needs.
Higher associaion with ICU admissions and mortality.
How does one calculate MAP
2/3DBP + 1/3SBP
Describe BP in Mild preeclampsia
130/80 to 140/95
Describe Proteinuria in Mild preeclampsia
300mg/24 hours
Describe platelets in Mild preeclampsia
Descibe Liver function in Mild preeclampsia
Describe Clotting studies in Mild preeclampsia
Describe bilirubin in Mild preeclampsia
Describe BP in Moderate Preeclampsia
Describe proteinuria in Moderate Preeclampsia
>5 gm/24 hours
Describe Platelets in Moderate Preeclampsia
Describe liver function in Moderate Preeclampsia
Elevated AST/ALT
Describe clotting studies in Moderate Preeclampsia
May be prolonged
Describe bilirubin in Moderate Preeclampsia
May be elevated
Describe the HELLP syndrome
Hemolysis, elevated liver enzymes and low platelet count reflect patients with greatest risk of mortality and morbidity
What are the ideal pharmacologic considerations for Hypertensive crisis?
1.Easy transition to PO
2.No increase in ICP
3.Absence of coronoary or cerebreal steal phenomenon
4.Minimal ADR
5.Low number of dose adjustments
6.Maintenance of BP control
7.Rapid onset
Goals of Therapy for Hypertensive crisis
-To lower BP or DBP over an ceeptable time frame based on severity of the crisis and individual tolerance without provoking cerebral or cardiac hypoperfusion, stroke or MI
Describe Goals of therapy for Hypertensive Emergency
Decrease MAP by 20-30% over 30-60 minutes or decrease DBP by 5-10mmHg q 5-10 min to a diastolic pressure of 100
Describe goals of therapy for Hypertensive urgency
Reduce DBP gradually over a period of 12-24 hours.
Hypertensive emergency requires _____ therapy
Hypertensive urgency requires ______ therapy
PO or IV
Sodium Nitroprusside MOA
Arterial and venous vasodilator which decreases preload and afterload
Sodium Nitroprusside Dose
0.5-1mcg/kg/min to max of 10
Sodium Nitroprusside effect on renal blood flow and myocardial oxygen demand
Under what conditions is Sodium Nitroprusside unstable?
Alkaline conditions and light
Sodium Nitroprusside Onset
30 seconds to 2 minutes
Sodium Nitroprusside, under what conditions is cyanide toxicity most likely?
high dose for 48 hours
Sodium Nitroprusside ADR
Hypotension with rapid infusion rates
Thiocyanate and cyanide toxicity
Labetolol MOA
Selective Alpha and non-selective beta blocker with alpha:beta ratio of 1:7
Labetolol Dose
20mg bolus then 0.5-2mg/min with max of 5mg/min
Labetolol Onset
5-15 minutes, lasts up to 2-12 hours after cessation
Labetolol PK
Extensive first pass metabolism therefore oral is only 20-40% bioavailable
Labetolol ADR
Heart Block
Orthostatic hypotension
Esmolol MOA
Cardioselective beta blocker, decreases sympathetic tone
Esmolol Dose
500mcg/kg over 1 min then 50mcg/kg/min with max 300mcg/kg/min (titrate every 5 minutes)
Esmolol PK
Very short duration, thus common in ICU
Esmolol Onset
Seconds and duration of 10-20 minutes after cessation
Describe esmolol metabolism
Occurs in erythrocytes by esterases and has metabolite (1/500th) activity eliminated in urine
Esmolol ADR
Fenoldopam MOA
DA1 agonist through dilation of coronary, renal (afferent/efferent) arteries
Fenoldopam Dose
1mcg/kg/min and increase by 0.05-0.02mcg/kg/min and then taper by 12% every 15-30 min
Fenoldopam Onset
5-15 minutes with duration of up to 30-60 minutes after cessation
Fenoldopam Metabolism
Hepatic w/ Cyp450
Fenoldopam ADR
Nicardipine MOA
2nd Gen DHP CCB that is selective for cerebral and coronary vessels
Nicardipine DOSE
5mg/hr titrate to max of 15mg/hr every 5 min by 2.5mg and oblus dosing not FDA approved
Nicardipine Onset
1-5 minutes and duration is 2-6 hours after cessation
Nicardipine binding
>95% bound
Does nicardipine have an effect on contractility?
No, its a DHP CCB
Nicardipine ADR
Reflex tachycardia
Nitroglycerin MOA
Potent vasodilator that decreases BP by decreasing preload and CO
Nitroglycerin Dose
5-100mcg/min, prime the tubing
Nitroglycerin Onset
2-5 minutes and DOA of 5 minutes
Nitroglycerin ADR
Hydralazine MOA
vasodilator that reduces TPR by direct action on vascular smooth muscle
Hydralazine Dose
10-20 mg IV q 6-8 hour
Hydralazine Onset
Initially slower onset 5-15 minutes then precipitous fall in BP lasting 12 hours
Problem with Hydralazine
Unpredictable effects on BP and is difficult to titrate
Hydralazine ADR
Aggravation of Angina
Enalapril MOA
Reduces serum aldosterone, reduce in TPR and afterload. ONLY IV ACEI
Dose Enalapril
0.625-5mg IV q 6 hours
Enalapril onset
15-30 minutes and DOA of 6 hours
Enalapril ADR
Precipitous fall in BP in high-renin states, variable response
1st line agent in hypertensive EMERGENCY