Hypertension is very common in patients presenting to the ED.
Acute end-organ dysfunction in the hypertension requires emergent diagnosis and treatment.
HYPERTENSIVE EMERGENCY
I. Definition:
· Hypertensive emergency (crisis): suddenly increase in systolic and
diastolic BP associated with acute end-organ damage (ie, CNS, heart, eyes, or kidneys).
Examples of end-organ injury include
1. Hypertensive encephalopathy
2. Acute aortic dissection
3. Acute pulmonary edema with respiratory failure
4. Acute MI or unstable angina
5. Preeclampsia or eclampsia
6. Acute renal failure
· Hypertensive urgency: severely elevated BP and chronic end-organ damage (eg, history of a stroke, MI, renal insufficiency)
II. History
1. Hypertensive encephalopathy.
Headache and AMS: classic findings.
The mental status changes: drowsiness, confusion, or coma.
May have seizures, blindness, or focal neurologic deficits.
2. Pulmonary edema. acute shortness of breath and chest pain and/or pressure.
They may also have slowly progressive symptoms of paroxysmal nocturnal dyspnea or orthopnea.
3. Myocardial ischemia. chest pain or signs of CHF may be the only presenting symptom.
4. Aortic dissection. severe chest or back pain.
Associated symptoms: neurologic deficits, syncope, and abdominal pain, nausea, vomiting, or diaphoresis.
5. Renal failure: hematuria,oliguria, or anuria, shortness of breath due to fluid retention.
Tips: A patient with elevated BP should be assessed for end-organ damage, beginning with historic factors, review of systems should address chest pain, back pain, shortness of breath, numbness, tingling, weakness, headache, visual disturbances, abdominal pain, and urinary tract complaints.
III. Physical Examination
1. Vital signs.
2. Neurologic examination: mental status changes or focal findings.
3. Cardiovascular examination should note murmurs, bruits, or pericardial rubs, S3, S4, BP should be check in both arms and a comparison made to readings in the lower extremities (a differential > 20 mm Hg suggests the presence of aortic dissection or coarctation)
4. Pulmonary examination. Crackles in patients with pulmonary edema.
5. Abdominal examination. Assess for pulsatile masses, tenderness
IV. Laboratory Studies
1. Urinalysis and BUN/creatinine.
2. Cardiac enzymes for patients complaining of chest pain, back pain, or shortness of breath.
3. ECG should be performed when there is suspicion of cardiac ischemia, arrhythmias, or conduction defects.
4. CXR pulmonary edema or suspected aortic dissection.
5. Head CT scan presenting with AMS, papilledema, or
focal neurologic deficits.
6. Chest and abdominal CT scan suspicion of aortic dissection.
7. Ultrasound to assess the kidneys and abdominal aorta.
V. Treatment:
1. Hypertensive emergency. immediate control of the BP to terminate
ongoing end-organ damage.
The goal is not to return BP to normal limits,but to reduce MAP by 20% in the first 1⁄2 hour. The exception to this rule is aortic dissection (reduced to 100–120 mm Hg)
2. Hypertensive urgency: gradually reduced over a period of 24 to 48 hours with oral medications.