Hypertension management in stroke

1. When should I treat severe  hypertension in patients with acute  brain  injury? Does treatment treshold/target differ between
patients?
TREATMENT target for different conditions vary
Ischemic Stroke – in acute setting (within first few hours after onset of symptoms) no need for active treatment
unless SBP > 220 or DBP > 110
HOWEVER, if patient is candidate for IV TPA, SBP should be lowered to target < 185
Intracerebral hemorrhage/Traumatic brain injury – No need for active treatment unless SBP persistenly > 180
Subarachnoid hemorrhage – in acute setting, BEFORE aneurysm has been secured, SBP target is < 140
After aneurysm has been secured, SBP is allowed to autoregulate (keeping wide parameter,
SBP 120-200)
Hypertensive Encephalopathy – SBP target reduction of 20-30% from baseline immediately, followed by
controlled BP < 160 (after ruling out critical vessel stenosis)
2. How do I treat severe hypertension in patients with acute  brain  injury?
Most patients with acute brain injury have reactive hypertension. Initial treatment includes prn boluses of IV medicationHydralazine 10 mg IV push or Enalapril 1.25 mg IV push or Labetalol 10 mg IV push. Failure of prn boluses to control blood pressure within 1 hour is an indication for starting continuous IV medication for BP control.
3. What IV medication may I use for continuous BP control?
If patient requires continuous IV medication for BP control, initiate .
Examples:
A. 70M with acute ischemic stroke, NIHSS 16, 12 hours from symptom onset, BP=200/100 HR 55.
1. Is BP management indicated? NO
2. If patient were seen 2 hours instead of 12 hours from symptom onset and no contraindication for IV TPA, is BP
management indicated? YES
2.1. What drug should you use? Hydralazine 10 mg IV push or Enalapril 1.25 mg IV push LABETALOL IS
CONTRAINDICATED due to bradycardia
2.2. If patient’s BP remains >180 despite 2 boluses, what medication can be started next to control BP? Since
HR < 60, you may use Nicardipine drip
2.3. If patient required continuous IV infusion for BP control and initial HR > 60, what is the ideal drug to use?
Labetalol drip.
2.4. When is nitroprusside drip indicated in this patient? IF patient fails to respond to the first agent (labetalol
or nicardipine depending on HR), then nitroprusside is a second like drug that may be used.
B. 40M SAH R MCA aneurysm, NOT yet secured, BP 200/80 HR 90.
1. IS BP management indicated? YES
2. What drug should you use? PRN medication may be used while waiting for the drip, but continuous IV medicationMUST be started ASAP. Since patient’s HR > 60, Labetalol drip may be started.
3. When is nitroprusside drip indicated in this patient? IF patient fails to respond to the first agent (labetalol or nicardipine depending on HR), then nitroprusside is a second like drug that may be used.

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