A patient on your ward complains of feeling “unwell” while you are on call in the middle of the night. Vital signs are as follows: HR 120, BP 210/115 (baseline BP is 140/85), RR 18, SpO2 98% on room air, T 37.2 (oral).
- What is the definition of a “Hypertensive Emergency?”
The definition of Hypertensive Emergency includes:
- Asymptomatic diastolic BP ≥ 130
- Hypertension with acute end organ damage:
- Hypertensive encephalopathy
- Acute aortic dissection
- Acute left ventricular failure
- Acute coronary syndrome
- Acute kidney injury
- Intracranial haemorrhage
- Acute ischemic stroke
- Preeclampsia/eclampsia (pregnancy after 20 weeks and up to six weeks postpartum).
A sudden change in blood pressure above SBP>180 and/or DBP>120, with or without symptoms, should warrant an investigation into end organ damage.
- What symptoms would you ask the patient about on history?
Symptoms to ask for on history:
- Headache (intracranial haemorrhage)
- Visual disturbance (increased ICP)
- Chest pain (ACS, aortic dissection)
- Back pain (aortic dissection)
- Dyspnea (CHF, pulmonary edema)
- Assess for signs of seizure/altered level of consciousness/stroke (hypertensive encephalopathy)
- What would you look for on physical exam?
Physical exam includes:
- Heart rate, respiratory rate, temperature, SpO2
- Blood pressure (both arms contemporaneously
- Neurological exam, LOC
- Fundoscopy – assess for exudates, retinal hemorrhages, papilledema
- Cardiac exam – new murmurs, S3, gallop
- Raised JVP
- Respiratory exam – crackles
- What investigations would you order at this time?
Investigations at this time include:
- CBC with peripheral smear (evidence of hemolysis)
- Lytes, BUN, Creatinine
- Serum cortisol
The goal of therapy should be rapid reduction of blood pressure (MAP decrease ≤25%) with antihypertensives, by IV if necessary.
- Hypertension Canada. Canadian Hypertension Education Program (CHEP) Recommendations. Retrieved from https://www.hypertension.ca/en/chep/
- Marik PE and Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care. 2011, 17:569-580.
- Vaughan CJ and Delanty N. Hypertensive emergencies. The Lancet. 2000, 356:411-417.