Hypertensive Emergency in Adults

Clinical Description

A severe and potentially life-threatening increase in blood pressures (BP) which may result in an acute stroke, retinopathy (grade 3-haemorrhage or 4-papilloedema), subarachnoid hemorrhage, seizures (hypertensive encephalopathy), heart attack, acute dissection of the aorta, heart failure, renal damage, or eclampsia (during pregnancy). The underlying cause may be primary hypertension; however, secondary causes of hypertension must be excluded. In adult patients this often occurs with a BP > 180/120 mmHg, while in children this may occur at lower BP levels.

Signs and Symptoms

• Encephalopathy, convulsions, retinal hemorrhages, or blindness.
• symptoms and signs of heart failure/stroke/heart attack/renal failure/aortic dissection

Investigations

• FBC, Urinalysis, Urea, electrolytes, and creatinine, Cardiac enzymes (CK-MB, AST, CK, LDH, troponin, BNP) for acute coronary syndrome, Chest X-ray, 12-lead ECG, Echocardiogram and kidney Ultrasound, Brain CT scan (for stroke), Chest CT scan with angiography (for suspected aortic dissection)

Treatment

• Reduce the blood pressure in a controlled manner to avoid impaired auto- regulation of cerebral blood flow.
• Manage target organ damage accordingly
• Control seizures if present
• Only use parenteral therapy in:
• Malignant hypertension with heart failure
• hypertensive encephalopathy
• eclampsia
• hypertension and dissecting aneurysm of the aorta

Note: Intravenous rapid lowering of blood pressure has several risks and should be done under close monitoring only, preferably in a high or intensive care setting. It is only indicated in hypertensive emergencies mentioned above.

Non-pharmacological

• appropriate positioning of patient if unconscious (to keep airway patent), raise head of bed if in heart failure

Pharmacological

• Give Hydralazine 5-10 mg IM/IV. Repeat up to every 1 hour as necessary.
• Alternatively, Labetalol, IV, Adults 20-50 mg STAT. (over a 2-minute period). Repeat at 10-minute intervals, if necessary, to a max. of 200 mg
• If no IV drugs and patient fully awake give Nifedipine 20mg slow release po
• If heart failure: add Frusemide 40 mg IV stat