zaki
Forum Guru
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Posts: 398
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A 37-year-old man comes to the emergency department complaining of headache and transient visual loss. He has not seen a physician in more than 10 years and takes no medication. He was told many years ago that he had high blood pressure but did not follow up with a health care provider. Initial physical examination shows him to be awake but slightly confused and irritable. He is afebrile. Pulse rate is 72/min, and blood pressure is 268/176 mm Hg. Eyeground examination reveals arteriovenous crossing changes and several hemorrhages, but no papilledema. Cardiac examination shows an S4 gallop; the lungs are clear. There is no peripheral edema.
Laboratory studies:
Hemoglobin 16.4 g/dL
Leukocyte count 6800/µL
Platelet count 115,000/µL
Serum electrolytes Normal
Blood urea nitrogen 32 mg/dL
Creatinine 1.7 mg/dL
Glucose 71 mg/dL
Urinalysis 1+ protein
The best treatment option would be:
A) Admit to the intensive care unit for treatment with intravenous nitroprusside, with initial goal blood pressure of 220/110 mm Hg.
(B) Admit to the intensive care unit for treatment with intravenous nitroprusside, with initial goal blood pressure of 160/90 mm Hg.
(C) Give nifedipine, 10 mg sublingually; admit to the intensive care unit for observation; repeat nifedipine dose if blood pressure is still greater
than 210/110 mm Hg in 1 hour
(D) Give nifedipine, 10 mg PO, and furosemide, 240 mg intravenously;
recheck in 1 hour.
(E) Give labetalol, 100 mg PO; recheck in 1 hour.
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Maverick
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C?
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A??
pls explain.
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| zaki
Forum Guru
Topics: 92
Posts: 398
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plz answer with reasoning not just abc or d
i will explain the answer latter
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Maverick
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| Elia Botros
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The best answer is B
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The aim is to drop B.P. to normal as soon as possible by the strongest antihypertensives as sodium nitroprosside
So the best is B
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i will go for A
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| Yulia
Forum Elite
Topics: 19
Posts: 240
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this patient has to be admitted to the icu for sure, because of malignant hypertension and encephalopathy.
iv nitroprusside is a drug of choice, it starts working in seconds and easily titrable, and i believe we could safely lower pt's bp to 220/110 initially. lowering it too much too quickly could bring up coronary or cerebral insufficiency.
option a would be correct then.
you can't give sublingual nifedipine, response is unpredictable, it can precipitate stroke or coronary ischemia.
labetalol could work, but po is not good enough.
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| jamil
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it is A.obviously we r dealing here with a hypertensive crisis,not due to the very high readings of ABP,but due to the accopmanying sypmtoms(headache and vision loss,...)SO the drug of choice in such situation is nitroprusside,and the goal is to decrease ABP slowaly,because a fast decrease in BP will lead to ischemic effect on brain.To remind,that nitroprusside is a very potent antihypertensive drug and its use shoul be monitored continously by arterial catheter.
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yes A is the answer
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| zaki
Forum Guru
Topics: 92
Posts: 398
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answer is a and here is the exp
This patient reports headache and transient visual loss and is found to be confused. The diagnosis of hypertensive encephalopathy is likely, even the absence of papilledema. Hypertensive encephalopathy is a diagnosis of exclusion, but there is no a priori evidence of stroke, seizure disorder, or encephalitis. Admission to the intensive care unit and immediate treatment with intravenous nitroprusside are indicated. Mean arterial blood pressure (MAP) should be lowered by no more than approximately 25%. In this case, admission MAP is 207 mm Hg (systolic blood pressure plus twice the diastolic blood pressure, divided by 3) and should be lowered quickly into the range of 150 to 160 mm Hg. A blood pressure of 220/110 mm Hg corresponds to a MAP of 147 mm Hg, which is acceptable. Lowering blood pressure to a level as low as 160/90 mm Hg (MAP, 133 mm Hg) carries the risk of provoking stroke or myocardial infarction. The initial target blood pressure should be maintained for several days, then gradually brought into normotensive range.
Oral or sublingual nifedipine can cause unpredictable falls in blood pressure and should not be used. Labetalol can be useful in cases of hypertensive crisis, but in this case, it would have to be given in the intensive care unit in the form of repeat intravenous boluses for rapid and controlled effect. Oral labetalol followed by continued observation in the emergency department is not adequate therapy in a case of hypertensive encephalopathy.
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Maverick
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