GIM Question 6 Instructor

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).

1. 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.

2. 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)
3. 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
4. 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
   • ECG
   • CXR
   • Urinalysis

The goal of therapy should be rapid reduction of blood pressure (MAP decrease ≤25%) with antihypertensives, by IV if necessary.

Resources:

1. Hypertension Canada. Canadian Hypertension Education Program (CHEP) Recommendations. Retrieved from https://www.hypertension.ca/en/chep/
2. Marik PE and Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care. 2011, 17:569-580.
3. Vaughan CJ and Delanty N. Hypertensive emergencies. The Lancet. 2000, 356:411-417.