Hypertensive emergency

High blood pressure without symptoms is NOT hypertensive emergency (see asymptomatic hypertension)

Background

• Definition: end-organ damage due to hypertension
  • Blood pressure is generally >180/120 (usually > 220/130), but presence of end-organ damage defines disease (not absolute blood pressure number)
  • 1%-6% of all ED patients will present with severe hypertension, but less than half of those will have target organ damage

Etiology

• Idiopathic
• Sympathomimetic drug use
• Preeclampsia
• Acute glomerulonephritis

Prehospital

• Prehospital BP measurements should be considered reliable
• Acute lowering of BP is not typically recommended
• Focus on ABCs (assess need for intubation or respiratory support)
• Provide care of treatable etiologies
  • CHF
  • Respiratory failure from pulmonary edema
  • Acute pain

Clinical Features

End-Organ Dysfunction

• Acute kidney injury
  • Often with microscopic hematuria
• Pulmonary edema
• Type-II myocardial infarction
• Hypertensive encephalopathy
  • Visual disturbances
  • Seizure
  • Delirium

Differential Diagnosis

Hypertension

• Hypertensive emergency
• Stroke
• Sympathetic crashing acute pulmonary edema
• Ischemic stroke
• Intracranial hemorrhage
• Preeclampsia/Eclampsia
• Autonomic dysreflexia
• Scleroderma renal crisis
• Acute glomerulonephritis
• Type- I myocardial infarction
• Volume overload
• Urinary obstruction
• Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
• Renal Artery Stenosis
• Nephritic and nephrotic syndrome
• Polycystic kidney disease
• Tyramine reaction
• Cushing's syndrome
• Obstructive sleep apnea
• Pheochromocytoma
• Hyperaldosteronism
• Hyperthyroidism
• Anxiety
• Pain
• Oral contraceptive use

Evaluation

Workup

Consider any of the following based on the patient's clinical presentation

• CBC with peripheral smear- assess for microangiopathic hemolytic anemia
• Chem 8 - assess renal failure and possible secondary causes
• Cardiac enzymes
• Urinalysis - Assess renal failure, glomerulonephritis, preeclampsia
• ECG - LVH, ischemia
• Ultrasound - evaluate for aortic dissection, bladder outlet obstruction, or depressed myocardial function
• Fundoscopic Exam - evaluate for hypertensive retinopathy or papilledema
• CXR - evaluate for pulmonary edema or dissection
• CT head - in hypertensive encephalopathy, may not show acute hemorrhage or other acute pathology
  • Hypertensive encephalopathy is thought to be secondary to alteration in cerebral auto-regulation leading to posterior reversible encephalopathy syndrome (now called reversible posterior leukoencephalopathy). Most patients will show changes on MRI, although this is not necessarily indicated in the emergency department.

Diagnosis

• Must have evidence of end-organ dysfunction
  • High blood pressure without symptoms is NOT hypertensive emergency (see asymptomatic hypertension)
  • Symptoms such as headache, epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction

Management

High blood pressure without end organ damage is NOT hypertensive emergency (see asymptomatic hypertension)

• Goal: Lower mean arterial or systolic pressure by no more than 10-20% in the first hour
  • Then lower by an additional 5-15% over the next 23 hours for no more than 25% in the first 24 hours
  • Exception is aortic dissection which requires rapid reduction to systolic BP to 100-120 mmHg
• Be careful of lowering BP in patients with CVA

By Drug

Drug	Dose	Mechanism	Pros	Cons	Notes
Nitroprusside	0.3-0.5 mcg/kg/min IV initial infusion Increase by 0.5 mcg/kg/min up to 2mcg/kg/min	Arterial > venodilator	1. Very effective 2. Immediate onset/offset	1. Cyanide Toxicity 2. Coronary steal? 3. Increased HR	1. Avoid in liver/renal failure 2. Avoid with increased ICP 3. Avoid in pregnancy
Nitroglycerin	Start 5-100 mcg/min	Veno>arteriodilation	1. Rapid on/offset 2. Increases coronary flow	Causes tachycardia	Drug of choice in patients with cardiac ischemia, LV dysfunction, or pulmonary edema
Labetalol	20-80mg IV bolus q10 min OR 0.5-2 mg/min IV infusion or 200mg to 400mg PO BID	Beta>α-blocker	1. No change in HR, cerebral flow 2. Rapid onset	Avoid in COPD, CHF and heart block	1. Consider in ACS 2. Consider in ischemic CVA
Esmolol	Load 250-500 mcg/kg over 2min Infuse 50 mcg/kg/min over 4min - if ineffective repeat load, increase infusion rate by  50mcg/kg/min up to 300mcg/kg/min	Beta selective	Rapid on/offset	Avoid in COPD, CHF bradycardia	Consider in ACS
Nicardipine	Start 5mg/h If ineffective after 15min increased in 2.5mg/hr interval up to 15mg/hr	Decreases PVR	Good for intracranial pathology	Slower onset/offset	Avoid in CHF, ACS
Phentolamine	5-15mg IV bolus q5-15min OR 0.2-0.5mg/min IV infusion	α-blocker			Used for catecholamine-induced hypertension
Enalaprilat	Bolus 1.25mg over 5min q6hr, titrate at 30min intervals to max of 5mg q6hr	Decreases HR, SV, systemic arterial pressure	Does not impair cerebral flow	Variable response	1. Used in patients at risk for cerebral hypotension, CHF 2. Avoid in pregnancy
Clonidine	0.1 - 0.3 mg PO q12 scheduled; For hypertensive emergency, 0.2 mg x1, then 0.1 mg q1 hr PRN, max 0.6 mg total	α-2 agonist, BP effects within 30-60 min after PO dose			Reduced CNS sympathetic flow, decreasing SVR, HR, BP; no renal blood flow changes; tolerance/tachyphylaxis develop quickly
Hydralazine	10 - 20 mg slow IV/IM bolus q4-6 hr PRN, max 40 mg/dose	Peripheral vasodilator, with fall in BP beginning within 30 min, lasting 2-4 hrs			Decrease in DBP > SBP; has increased HR, stroke volume and cardiac outpt; preferential vasodilation > venodilation

By Disease

Aortic Dissection

• Rapidly reduce sys BP to 100-120; HR 60-80 within 20min
• Adequate analgesia will decrease sympathetic drive and assist with BP and HR control
• Avoid volume depletion
• Prevent reflex tachycardia
  • Labetalol alone
  • Nitroprusside or nicardipine AFTER metoprolol or esmolol

Pulmonary Edema

• Reduce BP by 20-30%
• Promote diuresis AFTER vasodilation

ACS

• No more than 20-30% reduction for SBP >160
• Consider NTG, beta-blocker

Cocaine/Amphetamine Toxicitiy

• Benzos
• Mixed α + B blockade
  • Phentolamine OR nitroprusside AND β-blocker

Renal Failure

• Reduce BP by no more than 20%
• Avoid nitroprusside (renal metabolism)
• Labetalol or nicardipine

Eclampsia/Pre-eclampsia

• Goal BP <160/110
• Labetalol or nicardipine
• Magnesium

Hypertensive emergency

• Decrease MAP by 15-20%
  • Avoid overly aggressive lowering
• Nicardipine or labetalol

CVA

• SAH
  • See Subarachnoid Hemorrhage (SAH)
• ICH
• See current guidelines for best practice
  • Labetalol or Nicardipine or Esmolol
• Ischemic
  • If thrombolytic treatment is planned then goal systolic blood pressure 185 mm Hg and diastolic blood pressure 110 mm Hg
  • If no thrombolytics then consider blood pressure control if SBP >220 mmHg or DBP >120 mmgHg
  • Labetalol or Nicardipine are both effective and safe

Pheochromocytoma

• Phentolamine OR (nitroprusside AND β-blocker)

Disposition

• Admit
  • Patients receiving titratable antihypertensive therapies will likely require admission to critical care unit

See Also

• Hypertension (main)
• Asymptomatic hypertension
• IV nitroglycerine alternatives

External Links

• emDocs - Hypertensive Emergency: Pearls and Pitfalls for the ED Physician
• EMCrit - Hypertensive Emergency