Download - Fadhilatulkhair krisis hipertensi
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Definisi HIPERTENSI KRISISsuatu kedaruratan medik
yang ditandai dengan peningkatan TD secaramendadak dan dengan atau tanpa kerusakanorgan.
1 % dari populasi hipertensi dewasa Hipertensi Emergensi
- > 50% penderita di ICU- karena terapi tak adekuat
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Klasifikasi berdasarkan prioritas pengobatan
1. Hipertensi emergensi (darurat )2. Hipertensi urgensi ( mendesak )
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Table 2 : Algorithm for Triage Evaluation
Parameter
Severe Hypertension (Urgency)Hypertensive Emergency
symptomatic Symptomatic
Blood pressure
(mmHg)
> 180/110 > 180/110 Usually > 220/140
Symptoms Headache, anxiety;
often asymtomatic
Severe headache,
shortness of breath
Shortness of breath, chest pain,
nocturia, dysarthria, weakness,
altered consciousness
Examination No target organ
damage, no clinical
cardiovascular
disease
Target organ
damage; clinical
cardiovascular
disease present,
stable
Encephalopathy,pulmonary
edema, renal insufficiency,
cerebrovascular accident,
cardiac ischemia
Therapy Observe 1-3 hr;
initiate, resume
medication; increase
dosage of inadequte
agent
Observe 3-6 hr;
lower BP with
shortacting oral
agent; adjust
current therapy
Baseline laboratory tests;
intravenous line; monitor BP, may
initiate parenteral therapy in
emergency room
Plan Arrange follow-up
within 3-7 days; if no
prior evaluation,
schedule appointment
Arrange follow-up
evaluation in less
than 72 hr
Immediate admission to ICU;
treat to initial goal BP, additional
diagnostic studies
BP, Blood pressure; ICU, Intensive care unit
Sumber : Hebert e.j Prim Care 2008. 35 (3)
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DIAGNOSIS
ANAMNESIS
- Lama menderitahipertensi
- Obat-obat yangdikonsumsi
- Penyakit penyerta
PEMERIKSAAN FISIS
- Pengukuran tekanandarah
- Perabaan a. radialis,a. karotis
PEMERIKSAAN KHUSUS- Funduskopi
- Tes Urin
- dll
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Table : Manifestasi klinis hipertensi emergensi
BloodPressure(mmHg)
FunduscopicFindings
NeurologicStatus CardiacFindings RenalSymptoms GastrointestinalSymptoms
Usually
>220/140
Hemorrhages,
exudatespapiledema
Headache,confusion,
somnolence,stupor,visual loss,seizures,focalneurologicdeficits,
coma
Prominent
apical
pulsation,cardiaceniargement, congestiveheart failure
Azotemia,proteinuria
, oliguria
Nausea.vomiting
Sumber : Hebert e.j Prim Care 2008. 35 (3)
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PENGOBATANHipertensi Emergensi- Dirawat di ICU- Obat anti hipertensi parenteral- Target : - Penurunan tekanan darah pd jam
pertama 20-25 % MAP- Minimalisir hipoperfusi organ vital(eg: otak)
- Penurunan tekanan darah selanjutnya dl 24 jam
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Table : Treatment of Hypertensive EmergenciesAgent
Parenteral
Vasodilators
Dosage Onset/Duration of
Action (after
discontinuation)
Precautions
Sodium
Nitroprusside
0.25-10 g/kg/min as
IV infusion
Immediate/2-3 min
after infusion
Nausea, vomiting; prolonged use
may cause thiocyanate
intoxication,
methemoglobinemia, acidosis,
cyanide poisoning; bags, bottles,
delivery sets must be light
resistant
Nitroglycerin 5-100 g as IV
infusion
2-5 min/5-10 min Headache, tachycardia,
vomiting; flushing.
Methemoglobinemia; requiresspecial delivery system because
of drug binding to PVC tubing
Nicardipine 5-15 mg/hr as IV
infusion
1-5 min/15-30 min,
but may exceed 12
hr after prolonged
infusion
Tachycardia, nausea, vomiting,
headache, increased intracranial
pressure; hypotension may be
protracted after prolonged
infusions
Fenoldopam
Mesylate
0.1-0.3 g/kg/min as IV
infusinon
1 hr (IV);
20-30 min IM/4-6 hr
(IM
Tachycardia, headache,
vomiting, aggravation of angina
pectoris, sodium and water
retension, increased intracranial
pressure
Sumber : Hebert e.j Prim Care 2008. 35 (3)
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Tabel : Medikamentosa untuk keadaan2 khusus hipertensiemergensi
Emergenci dengan
keadaan khusus
Pengobatan Target TD
Aortic dissection
AMI, ischemia
Pulmonary edema
Renal emergencies
Catecholamine excess
Hypertensive encphalopathy
Subarachnoid hemorrhage
Ischemic stroke
Nitroprusside + esmolol
Nitroglycerin, nitroprusside, nicardipine
Nitroprusside, nitroglycerin, labetalol
Fenoldopam, nitroprusside, labetalol
Phentolamine, labetalol
Nitroprusside
Nitroprusside, nimodipine, nicardipine
Nitroprusside (controversial), nicardipine
110-120 SBP as soon as possible
Secondary to ischemia relief
Improve symptoms 10%-15% in 1-2hr
Target BP 20%-25% in 2-3 hr
Control paroxysms, 10 %-15% in 1-2hr
20%-25% in 2-3 hr
20%-25% in 2-3 hr
0%-20% in 6-12 hr
Sumber : Hebert e.j Prim Care 2008. 35 (3)
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PENGOBATAN
Hipertensi Urgensi- Medikamentosa Oral anti hipertensi yg
bekerja cepat
- Jika Target tidak tercapai, tingkatkandosis
- Target tercapai dalam 3-7 hari
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Table : Management of Hypertensive Urgencies
GENT DOSE
ONSET/DURATION OF
ACTION
(AFTERDISCONTINUATION)
PRECAUTIONS
Captopril 25 mg p.o., repeat as
needed SL, 25 mg
15-30 min/6-8 h SL,
15-30 min/2-6 h
Hypotension, renal
failure in bilateral
renal artery
stenosis
Clonidine 0.1-0.2 mg p.o., repeat
hourly as required tototal dose of 0.6 mg
30-60 min/8-16 h Hypotension,
drowsiness, drymouth
Labetalol 200-400 mg p.o repeat
every 2-3 h
30 min-2 h/2-12 h Bronchoconstrictio
n, heart block,
orthostatic
hypotension
Amblodipin 2,5-5 mg 1-2 hr/12-18 hr Tachycardia,hypotension
Nifedipin 5 mg sl 5-20 min/2-6 hr Tachycardio,
hypotension
Adapted with permission from Vidt DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens
(Greenwich). 2004;6:520-525Sumber :
-Hebert C.J Hypertensive Crises Prim Care 2008. 35 (3)
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PROGNOSIS
Angka kematian tinggi
Tanpa terapi : 1 year survival rate 10-
20% Terapi adekuat : 5 year survival rate
50-60%
Kaplan, clinical hypertension