Podcast #36 - Primer on Clinically Important Hypertension in the Emergency Department
This week's podcast is all about hypertension. Like a previous podcast, #13 on abscess management, this podcast is in response to a recent Skeptic's Guide to Emergency Medicine (SGEM) post that TOTAL EM was featured on. We want to add to that discussion by expanding on clinically important hypertension in the emergency department. This primer will most likely only be the start to future discussions on deeper reviews about hypertension that we need to be concerned about in emergencies.
First, the recent podcast regarding hypertension on the SGEM was concerning the ATACH-2 trial. In that podcast, we reviewed how intensive blood pressure lowering did not result in a decrease in death or disability compared to standard lowering. Listen to this podcast and read the blog for more details on this excellent in-depth review.
Now, we need to discuss the differences between emergent and non-emergent hypertension. There have been many names of differentiating the two but one way to separate them is calling it "clinically important hypertension." This avoids the whole "urgent" and "emergent" problems we face today. Instead, we think of this as if the hypertension is clinically important to the emergency setting. Although still not a perfect definition it reminds us how hypertension needs to be managed in the busy ED of today.
Essential hypertension does need to be managed, but on an outpatient setting. The patient presenting with a benign elevation of their blood pressure does not emergent intervention. Those patients who need our immediate care are obviously sick. This is probably the biggest take-home point that so many forget when managing patients. If they are without symptoms and otherwise look appropriate, they are most likely appropriate for discharge home with outpatient follow-up and management. There is an ACEP clinical guideline essentially stating the same for most cases. This policy also states that routine screening is not necessary. Another ACEP policy further supports avoiding over-treatment by discouraging rapid lowering of blood pressure in the asymptomatic patient. Remember that lowering blood pressure rapidly is not without its own risks and can lead to potentially serious harms to patients with unintended adverse events.
When it comes to management of patients who have emergencies with a side of hypertension, as Scott Weingart would put it, there are several main points. Again, these patients will look sick. There are also the key points of pain control prior to giving anti-hypertensives with a goal of rapidly lowering the blood pressure by approximately 25% in the first hour. Scott Weingart also mentions medications in a quick review that is worth listening to in detail.
There are some other great reviews to look at when it comes to those clinically important hypertension cases. One update in a paper is located here which includes a nice quick review on key medications. Also check EM Updates which covers some of the main conditions and their first-line treatments. Another favorite review given its simplicity is from Urgent Care RAP which is more for those in the urgent care or fast track setting. However, definitely worth the listen and review for a quick update that still is available at this time as #FOAMed.
As mentioned above, we plan on returning to this topic most likely in stages so stay tuned. In the meantime there are a couple of upcoming events we will be attending. The first is SEMPA 360 located this year in Phoenix, Arizona and then the Podcasting Course in Lexington, Kentucky. If you are attending let us know as we would love to meet you.
Also please let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at firstname.lastname@example.org, or send a message from the page. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere.
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