高血压英文ppt精品课件hypertension and peripheral vascular

Hypertension and Peripheral Vascular Disease EMS Professions Temple College Hypertension Resting BP consistently 140 systolic or 90 diastolic Epidemiology n 20% of adult population 35,000,000 people n 25% do not know they are hypertensive n Twice as frequent in blacks than in whites n 25% of whites and 50% of blacks 65 y/o Types nPrimary (essential) hypertension nSecondary hypertension Primary Hypertension n 85 - 90% of hypertensives n Idiopathic n More common in blacks or with positive family history n Worsened by increased sodium intake, stress, obesity, oral contraceptive use, or tobacco use n Cannot be cured Secondary Hypertension n10 - 15% of hypertensives nIncreased BP secondary to another disease process Secondary Hypertension n Causes: Renal vascular or parenchymal disease Adrenal gland disease Thyroid gland disease Aortic coarctation Neurological disorders n Small number curable with surgery Hypertension Pathology n Increased BP inflammation, sclerosis of arteriolar walls narrowing of vessels decreased blood flow to major organs n Left ventricular overwork hypertrophy, CHF n Nephrosclerosis renal insufficiency, failure Hypertension Pathology n Coronary atherosclerosis AMI n Cerebral atherosclerosis CVA n Aortic atherosclerosis Aortic aneurysm n Retinal hemorrhage Blindness Signs/Symptoms n Primary hypertension is asymptomatic until complications develop n Signs/Symptoms are non-specific Result from target organ involvement n Dizziness, flushed face, headache, fatigue, epistaxis, nervousness are not caused by uncomplicated hypertension. HTN Medical Management n Life style modification Weight loss Increased aerobic activity Reduced sodium intake Stop smoking Limit alcohol intake HTN Medical Management n Medications Diuretics Beta blockers Calcium antagonists Angiotensin converting enzyme inhibitors Alpha blockers HTN Medical Management Medical management prevents or forestalls all complications Patients must remain on drug therapy to control BP Categories of Hypertension n Hypertensive Emergency (Crisis) acute BP with sx/sx of end-organ injury n Hypertensive Urgency sustained DBP 115 mm Hg w/o evidence of end-organ injury n Mild Hypertension DBP 90 but venous 10-20 mg slow IV q 4-6 hrs; initial dose 5 mg for pre-eclampsia/eclampsia Usually combined with other agents such as beta blockers concern for reflex sympathetic tone increase Most useful in pre-eclampsia and eclampsia Drug Therapy Possibilities n Metoprolol (Lopressor), or Labetalol (Normodyne) decrease in heart rate and contractility Dose Metoprolol: 5 mg slow IV q 5 mins to total 15 mg Labetalol: 10-20 mg slow IV q 10 mins Metoprolol is selective beta-1 minimal concern for use in asthma and obstructive airway disease Labetalol: both alpha & beta blockade Most useful in AMI and Unstable angina Hypertensive Crisis Management Avoid crashing BP to hypotensive or normotensive levels! Ischemia of vital organs may result! Hypertensive Crisis Management nMust assure underlying cause of BP is understood HTN may be helpful to the patient Aggressive treatment of HTN may be harmful What patients may have HTN as a compensatory mechanism? Syncope Sudden, temporary loss of consciousness caused by inadequate cerebral perfusion Vasovagal Syncope n Simple fainting occurring when upright n Increased vagal tone leads to peripheral vasodilation, bradycardia which lead to: Decreased cardiac output Decreased cerebral perfusion n Causes Fright, trauma, pain Pressure on carotid sinus (tight collar, shaving) Cardiogenic Syncope n Paroxysmal Tachyarrhythmias (atrial or ventricular) n Bradyarrhythmias Stokes-Adams attack n Valvular disease especially aortic stenosis n Can occur in any position Postural Syncope Due to decreased BP on standing or sitting up Orthostatic hypotension Postural Syncope n Drugs - usually antihypertensives Diuretics Vasodilators Beta-blockers n Volume depletion Acute hemorrhage Vomiting or diarrhea Excessive diuretic use Protracted sweating n Neuropathic diseases - diabetes Tussitive Syncope nCoughing nIncreased intrathoracic pressure Decreased venous return nVagal stimulation Decreased heart rate Micturation Syncope nUrination nIncreased vagal tone Decreased cardiac output nFrequently associated with Volume depletion due to EtOH Vasodilation due to EtOH Syncope History n What were you doing when you fainted? n Did you have any warning symptoms? n Have you fainted before? n Under what circumstances? n Any history of cardiac disease? n Any medications? n Any other past medical history? Syncope Management n Supine position - possibly elevate lower extremities Do not sit up or move to semi-sitting position quickly n Airway - oxygen via NRB n Loosen tight clothing Syncope Management n Vital signs, Focused Hx & Physical exam Assess for injuries sustained in fall Attempt to identify cause n Based on history/physical, Consider: ECG Monitor Blood glucose check Vascular access Transport for further evaluation Peripheral Vascular Disease Peripheral Atherosclerotic Disease Deep Vein Thrombophlebitis Varicose Veins Peripheral Atherosclerosis n Gradual, progressive disease n Common in diabetics n Thin, shiny skin n Loss of hair on extremities n Ulcers, gangrene may develop Peripheral Atherosclerosis n Intermittent Claudication Deficient blood supply in exercising muscle Pain, aching, cramps, weakness Occurs in calf, thigh, hip, buttocks on walking Relieved by rest (2 - 5 minutes) Peripheral Atherosclerosis n Acute Arterial Occlusion Sudden blockage by embolism, plaque, thrombus Can result from vessel trauma The 5 Ps of acute occlusion Pain, worsening over several hours Pallor, cool to touch Pulselessness Paresthesias, loss of sensation Paralysis Deep Vein Thrombophlebitis n Inflammation of lower extremities, pelvic veins with clot formation n Usually begins with calf veins n Precipitating factors Injury to venous endothelium Hypercoagulability Reduced blood flow (venous stasis) Deep Vein Thrombophlebitis n Signs/Symptoms May be asymptomatic Pain, tenderness Fever, chills, malaise Edema, warmth, bluish-red color Pain on ankle dorsiflexion during straight leg lifting (Homans sign) Palpable “cord” in calf clotted veins Deep Vein Thrombophlebitis May progress to pulmonary embolism! Varicose Veins Dilated, elongated, tortuous superficial veins usually in lower extremities Varicose Veins n Causes Congenital weakness/absence of venous valves Congenital weakness of venous walls Diseases of venous system (Deep thrombophlebitis) Prolonged venostasis (pregnancy, standing) Varicose Veins n Signs/Symptoms May be asymptomatic Feeling of fatigue, heaviness Cramps at night Orthostatic edema Ulcer formation Varicose Veins Rupture may cause severe bleeding Control with elevation and direct pressure Aortic Aneurysm Localized abnormal dilation of blood vessel, usually an artery Thoracic Dissecting Abdominal Thoracic Aortic Aneurysm nUsually results from atherosclerosis nWeakened aortic wall bows out - lumen distends nMost common in males age 50 - 70 Thoracic Aortic Aneurysm n Sign/Symptoms Dyspnea, Cough Hoarseness/Loss of voice Substernal/back pain or ache Lower extremity weakness/ paresthesias Variation in pulses, BP between extremities Dissecting Aortic Aneurysm n Intima tears n Column of blood forms false passage, splits tunica media lengthwise n Most common in thoracic aorta n Most common in blacks, chronic hypertension, Marfans syndrome Dissecting Aortic Aneurysm n Signs/Symptoms Sudden “ripping” or “tearing” pain anterior chest or between shoulders May extend to shoulders, neck, lower back, and abdomen Rarely radiates to jaw or arms Pallor, diaphoresis, tachycardia, dyspnea Dissecting Aortic Aneurysm n Signs/Symptoms Normal or elevated upper extremity BP in “shocky” patient CHF if aortic valve is involved Acute MI if coronary ostia involved Rupture into pericardial space or chest cavity with circulatory collapse Dissecting Aortic Aneurysm n Signs/Symptoms CNS symptoms from involvement of head/neck vessel origins Chest pain + neurological deficit = aortic aneurysm Abdominal Aortic Aneurysm nAlso referred to as “AAA” or “Triple A” nUsually results from atherosclerosis nWhite males age 50 - 80 Abdominal Aortic Aneurysm n Signs/Symptoms Usually asymptomatic until large enough to be palpable as pulsing mass Usually tender to palpation Excruciating lower back pain from pressure on lumbar vertebrae May mimic lumbar disk disease or kidney stone Leaking/rupture may produce vascular collapse and shock Often presents with syncopal episode Abdominal Aortic Aneurysm n Signs/Symptoms May result in unequal lower extremity pulses or unilateral paresthesia Urge to defecate caused by retroperitoneal leaking of blood Erosion into duodenum with massive GI bleed Aortic Aneurysm Management n ABCs n High concentration O2 NRB n Assist ventilations if needed n Package patient for transport in MAST, inflate if patient becomes hypotensive n IVs x 2 with LR enroute Draw labs n 12 Lead ECG enroute if time permits Aortic Aneurysm Management n If patient hypertensive consider reducing BP Nitropaste Beta blocker n Consider analgesia Tolerated best if hypertensive n Consider transport to facility with vascular surgery capability Pulmonary Embolism nPathophysiology Pulmonary artery blocked Blood: Does not pass alveoli Does not exchange gases Causes nBlood clots = most common cause nVirchows Triad Venous stasis bed rest, immobility, casts, CHF Thrombophlebitis vessel wall dama