1. Edward P. Sloan, MD, MPH, FACEP Emergency Department Hypertensive Patient Emergencies: Case Presentations and Panel Discussion

2. Edward P. Sloan, MD, MPH, FACEP Atlantic City, NJ September 24, 2007 2007 EMA Advanced Emergency & Acute Care Medicine Conference Atlantic City, NJ September 24, 2007

3. Edward P. Sloan, MD, MPH, FACEP Edward P. Sloan, MD, MPH FACEP Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL

4. Edward P. Sloan, MD, MPH, FACEP Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL

5. Edward P. Sloan, MD, MPH, FACEP Disclosures FERNE Chairman and President FERNE Chairman and President FERNE advisory board for The Medicine Company in May 2007 FERNE advisory board for The Medicine Company in May 2007 FERNE grant by The Medicines Company to support this program FERNE grant by The Medicines Company to support this program No individual financial disclosures No individual financial disclosures

6. Edward P. Sloan, MD, MPH, FACEP www.ferne.org

7. Learning Objectives Determine the definition of hypertensive emergencies, and discuss their epidemiology and pathophysiology in ED patients with stroke syndromes. Determine the definition of hypertensive emergencies, and discuss their epidemiology and pathophysiology in ED patients with stroke syndromes. Identify what therapies are available for the treatment of ED patients with hypertensive emergencies and stroke syndromes. Identify what therapies are available for the treatment of ED patients with hypertensive emergencies and stroke syndromes.

8. Edward P. Sloan, MD, MPH, FACEP Learning Objectives Discuss the clinically relevant endpoints for the evaluation and management of ED patients with hypertensive emergencies. Discuss the clinically relevant endpoints for the evaluation and management of ED patients with hypertensive emergencies. Understand what guidelines and recommendations assist emergency care providers in optimally treating ED patients with hypertensive emergencies and stroke syndromes. Understand what guidelines and recommendations assist emergency care providers in optimally treating ED patients with hypertensive emergencies and stroke syndromes.

9. Edward P. Sloan, MD, MPH, FACEP Case Presentation A 64 year old male patient with a history of hypertension and diabetes presents to the Emergency Department with a new onset of ipsilateral right-sided facial droop, arm and leg weakness, aphasia, and gaze to the left. His vital signs are BP 240/135, HR110, RR 16, and Temp 98.4.

10. Edward Sloan, MD, MPH, FACEP ED Neuroprotection: Key Concepts Outcome related to infarct volume Need to limit infarct size Aggressively Rx ischemic penumbra

11. Edward Sloan, MD, MPH, FACEP ED Neuroprotection: Key Concepts Outcome related to infarct volume

12. Edward Sloan, MD, MPH, FACEP Infarct Volume and Outcome Vessel occlusion Infarct core Ischemic penumbra How large is the core in the ED? What is the penumbra conversion? Do ED therapies limit infarct growth?

13. Edward Sloan, MD, MPH, FACEP ED Neuroprotection: Key Concepts Outcome related to infarct volume Need to limit infarct size

14. Edward Sloan, MD, MPH, FACEP Limiting Infarct Size Enhance perfusion Treat hypoxia, hypotension Limit ischemic cascade effects Prevent complications the astonis hing results Compare the results with a conventional training protocol. Most people do at least two exercises per muscle group, perform three sets and perhaps 12 or 15 reps per set. Allowing just five seconds per rep, that makes for at least 36 minutes of exercise per workout. This is usually done three times per week. So in six weeks, a conventional program would involve 648 minutes of exercise. That's 42 times more than the subjects in our study. Are your results in the last six weeks 42 times better than theirs? I doubt it. perform ance improve ment Remember, these golfers were exercising in a way that did not involve stretching or moving the weight over a full range of motion. So how did this affect a full range of motion activity like a golf drive? Every one of them showed an improvement. The increase in drive distance varied from 5 to 31 yards. Keep in mind that these subjects had been golfing for up to 40 years and had handicaps as low as eleven. So getting any improvement in golfers who already play at this level is impressive. Getting it with 14 minutes of exercise spread over six weeks is truly revolutionary. The fact is every sport -- even a finesse sport like golf -- is improved by an increase in strength. Muscles are responsible for all movement in the body and stronger muscles deliver more power to every aspect of movement, irrespective of its range of motion.increase in strength Since this study, I've gone on to improve this method of training. Further research showed that static hold times could be reduced to even less than what the golfers used. Workouts can be spaced further apart as a trainee gets stronger. I work with advanced trainees who train once every six weeks, yet they gain strength on every exercise each time they work out. The weights they hoist are enormous. I believe the time is coming when most people will have a better understanding of the role of proper, efficient strength training methods and frequency. For the guy who wants maximum results with minimum time invested, an ultra-brief but ultra-intense workout will be performed about as often as he gets a haircut. Anything more is just lifting weights as a busy work hobby. Train smart!

15. Edward Sloan, MD, MPH, FACEP Preventing Complications the astonis hing results Compare the results with a conventional training protocol. Most people do at least two exercises per muscle group, perform three sets and perhaps 12 or 15 reps per set. Allowing just five seconds per rep, that makes for at least 36 minutes of exercise per workout. This is usually done three times per week. So in six weeks, a conventional program would involve 648 minutes of exercise. That's 42 times more than the subjects in our study. Are your results in the last six weeks 42 times better than theirs? I doubt it. perform ance improve ment Remember, these golfers were exercising in a way that did not involve stretching or moving the weight over a full range of motion. So how did this affect a full range of motion activity like a golf drive? Every one of them showed an improvement. The increase in drive distance varied from 5 to 31 yards. Keep in mind that these subjects had been golfing for up to 40 years and had handicaps as low as eleven. So getting any improvement in golfers who already play at this level is impressive. Getting it with 14 minutes of exercise spread over six weeks is truly revolutionary. The fact is every sport -- even a finesse sport like golf -- is improved by an increase in strength. Muscles are responsible for all movement in the body and stronger muscles deliver more power to every aspect of movement, irrespective of its range of motion.increase in strength Since this study, I've gone on to improve this method of training. Further research showed that static hold times could be reduced to even less than what the golfers used. Workouts can be spaced further apart as a trainee gets stronger. I work with advanced trainees who train once every six weeks, yet they gain strength on every exercise each time they work out. The weights they hoist are enormous. I believe the time is coming when most people will have a better understanding of the role of proper, efficient strength training methods and frequency. For the guy who wants maximum results with minimum time invested, an ultra-brief but ultra-intense workout will be performed about as often as he gets a haircut. Anything more is just lifting weights as a busy work hobby. Train smart!

16. Edward Sloan, MD, MPH, FACEP ED Neuroprotection: Key Concepts Outcome related to infarct volume Need to limit infarct size Aggressively Rx ischemic penumbra

17. Edward Sloan, MD, MPH, FACEP Aggressively Rx Ischemic Penumbra Maximize cerebral perfusion Provide optimal substrates, O2 Avoid cell death Maintain intact blood brain barrier

18. Edward Sloan, MD, MPH, FACEP Cerebral Perfusion CPP = MAP - ICP Cerebral perfusion pressure Mean arterial pressure Intracranial pressure

19. Edward Sloan, MD, MPH, FACEP Cerebral Perfusion CPP = MAP - ICP If MAP = 110 mmHg, ICP 10 mmHg CPP then equals 100 mmHg Cerebral blood flow auto-regulation CPP maintained over range of MAPs Pathological ICP elevations limited

20. Edward Sloan, MD, MPH, FACEP Mean Arterial Pressure 120 / 75MAP = 90 mmHg 210 / 120MAP = 150 mmHg 180 / 110MAP = 132 mmHg How much MAP therapy is OK? What agents provide best Rx? How to avoid watershed infarct?

21. Edward Sloan, MD, MPH, FACEP Watershed Infarct wa·ter·shed (wô t r-sh d) n. 1. A ridge of high land dividing two areas that are drained by different river systems. Also called water parting. 2. The region draining into a river, river system, or other body of water. 3. A critical point that marks a division or a change of course; a turning point: watershed infarction n. Infarction of the cerebral cortex in an area of blood supply between two major cerebral arteries.

22. Edward Sloan, MD, MPH, FACEP ED Neuroprotection: Key Concepts Outcome related to infarct volume Need to limit infarct size Aggressively Rx ischemic penumbra ED MD is the best neuroprotectant

23. Robert A. Giles, MD, FACEP MAP Calculation BP 240/135 MAP = 1/3 SBP + 2/3 DBP One third systolic = 80 Two thirds diastolic = 90 MAP = 170 mm Hg

24. Robert A. Giles, MD, FACEP ED Patient BP Management BP 240/135 MAP = 170 mm Hg 25% reduction?? MAP = 130 mm Hg BP 180/105

25. Edward P. Sloan, MD, MPH, FACEP Key Clinical Question How should this hypertensive emergency be managed in the setting of this stroke syndrome in order to minimize the risk of hemorrhage and to maximize the chance for a good outcome for this patient? How should this hypertensive emergency be managed in the setting of this stroke syndrome in order to minimize the risk of hemorrhage and to maximize the chance for a good outcome for this patient?

26. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Are hypertensive urgency and emergencies as well as the need to treat ED patients defined mostly by the severity of end organ illness manifested by the patient as opposed to the actual BP value? Are hypertensive urgency and emergencies as well as the need to treat ED patients defined mostly by the severity of end organ illness manifested by the patient as opposed to the actual BP value?

27. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Is the amount of desired blood pressure reduction based on the initial BP value, the end organ involved, the severity of illness, complication risk, or the apparent response to therapy that the ED patient manifests during the therapy? Is the amount of desired blood pressure reduction based on the initial BP value, the end organ involved, the severity of illness, complication risk, or the apparent response to therapy that the ED patient manifests during the therapy? What is that amount? What is that amount?

28. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Is there a consensus in the ED community on an optimum value or range of BP values at which therapy can be terminated because of success in reaching a therapeutic endpoint? Is there a consensus in the ED community on an optimum value or range of BP values at which therapy can be terminated because of success in reaching a therapeutic endpoint? Who determines this consensus? Who determines this consensus?

29. Edward P. Sloan, MD, MPH, FACEP Clinical Questions What is this optimal endpoint in the treatment of hypertensive blood pressure management, and is it based upon Systolic BP, Diastolic BP, Mean Arterial BP, or some end organ function? What is this optimal endpoint in the treatment of hypertensive blood pressure management, and is it based upon Systolic BP, Diastolic BP, Mean Arterial BP, or some end organ function? Why? Why?

30. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Does this optimal therapeutic endpoint need to be modified based on the type of stroke syndrome such as acute ischemic stroke as compared to intracerebral hemorrhage or subarachnoid hemorrhage? Does this optimal therapeutic endpoint need to be modified based on the type of stroke syndrome such as acute ischemic stroke as compared to intracerebral hemorrhage or subarachnoid hemorrhage?

31. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Does this optimal therapeutic endpoint need to be modified based on specific other end organ involvement, such as acute renal failure or acute myocardial infarction? Does this optimal therapeutic endpoint need to be modified based on specific other end organ involvement, such as acute renal failure or acute myocardial infarction?

32. Edward P. Sloan, MD, MPH, FACEP Clinical Questions What are the optimal medication therapies available to manage the blood pressure of the patient with a hypertensive emergency? What are the optimal medication therapies available to manage the blood pressure of the patient with a hypertensive emergency? Is there a “best choice” therapy? Is there a “best choice” therapy? Why? Why?

33. Edward P. Sloan, MD, MPH, FACEP Clinical Questions What drugs do you most commonly use to treat ED patients with hypertensive emergencies as well as those who have a concomitant stroke syndrome? What drugs do you most commonly use to treat ED patients with hypertensive emergencies as well as those who have a concomitant stroke syndrome?

34. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Do you use esmolol? Do you use esmolol? Do you use labetalol? Do you use labetalol? Do you use nitrogycerine? Do you use nitrogycerine? Do you use sodium nitroprusside? Do you use sodium nitroprusside? How? Why? How? Why?

35. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Do you use nicardipine? Do you use nicardipine? Do you use hydralazine? Do you use hydralazine? Do you use enalaprilat? Do you use enalaprilat? Do you use fenoldopam? Do you use fenoldopam? Do you use phentolamine? Do you use phentolamine? How? Why? How? Why?

36. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Do you use oral agents? Do you use oral agents? Do you unit dose for IVP agents? Do you unit dose for IVP agents? Do you avoid continuous infusion Rx? Do you avoid continuous infusion Rx? Do you mix agents? Do you mix agents? How? Why? How? Why?

37. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Is there an optimal time course for treatment of elevated blood pressure? Is there an optimal time course for treatment of elevated blood pressure? If yes, can this standard be implemented in all comprehensive Emergency Departments, or should it be achieved optimally in the intensive care unit? If yes, can this standard be implemented in all comprehensive Emergency Departments, or should it be achieved optimally in the intensive care unit?

38. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Is there a specific perspective of the treating nurse regarding what we do and how we can improve the process and patient outcomes? Is there a specific perspective of the treating nurse regarding what we do and how we can improve the process and patient outcomes?

39. Edward P. Sloan, MD, MPH, FACEP Clinical Questions How are we recording these changing Vitals and Blood Pressures that are automatically generated? How are we recording these changing Vitals and Blood Pressures that are automatically generated? Are they a part of the RN or MD electronic medical record? Are they a part of the RN or MD electronic medical record? Can they be retrieved retrospectively? Can they be retrieved retrospectively?

40. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Should patients with hypertensive emergencies be treated in the EMS setting? Should patients with hypertensive emergencies be treated in the EMS setting? How? How?

41. Edward P. Sloan, MD, MPH, FACEP Clinical Questions What published guidelines should be studied by all EMS and ED emergency care providers because of their broad scope and proven clinical relevance and applicability to successful hypertension management, enhanced reperfusion and neuroprotection, and correlation to improved clinical outcome? What published guidelines should be studied by all EMS and ED emergency care providers because of their broad scope and proven clinical relevance and applicability to successful hypertension management, enhanced reperfusion and neuroprotection, and correlation to improved clinical outcome?

42. Edward P. Sloan, MD, MPH, FACEP Clinical Questions What are the medico-legal implications of the ED management of patients with hypertensive emergencies and those with concomitant stroke syndromes? What are the medico-legal implications of the ED management of patients with hypertensive emergencies and those with concomitant stroke syndromes?

43. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Are there any as of yet not discussed or resolved issues? Are there any as of yet not discussed or resolved issues? Is there any other important information to discuss? Is there any other important information to discuss?

44. Edward P. Sloan, MD, MPH, FACEP Conclusions Medicine is an art, not a science Medicine is an art, not a science Vice versa is also true Vice versa is also true We conduct clinical trials every day We conduct clinical trials every day Therapeutic trials, N = 1 Therapeutic trials, N = 1 We observe and converge towards a unified approach without knowing it We observe and converge towards a unified approach without knowing it This session assists in the process This session assists in the process

45. Edward P. Sloan, MD, MPH, FACEP Questions? www.FERNE.org edsloan@uic.edu 312 413 7490 ferne_ema_2007_htn_emergencies_panel_sloan_cases_panel_092407_finalcd 5/3/2015 4:57 PM

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