� Imaging

Obtain a head computed tomography (CT), searching for

signs of hypertensive encephalopathy or intracranial hem ­

orrhage in patients presenting with altered mental status,

papilledema, focal neurologic deficits, or seizure. Order a

chest x-ray (CXR) to look for signs of flash pulmonary

edema or aortic dissection in patients with chest pain, back

pain, or shortness of breath. Pursue CT angiography of the

chest and abdomen in patients with suspicion of aortic

dissection.

MEDICAL DECISION MAKING

Rapidly evaluate all patients with severe hypertension for

the presence of hypertensive emergency (hypertensive

encephalopathy, intracranial hemorrhage, flash pulmonary

edema, acute coronary syndrome, aortic dissection, and

HYPERTENSIVE EMERGENCIES

Severe hypertension (BP > 1 80/1 1 0)

History and physical exam, re-measure BP

Gradual normal ization of

BP over 24-48 hours with

oral anti-hypertensives

Figure 1 8-1. Hypertensive emergency diagnostic algorithm. BP, blood pressure; ECG, electroca rdiogram.

acute kidney injury). Utilize the history and physical exam

to help narrow the differential diagnosis and obtain the

appropriate laboratory and imaging studies to both confirm

end-organ injury and guide further therapy (Figure 1 8-1

and Table 18-1).

TREATMENT

Hypertensive emergency requires immediate BP reduc ­

tion to limit continuing end-organ damage. The goal is

not to normalize the BP ( < 140/90 mmHg), but rather to

Table 1 8-1. Hypertensive emergency diag noses with findings.

Diagnosis

Hypertensive encephalopathy

Intracranial hemorrhage

Acute pulmonary edema

Acute coronary syndrome

Aortic dissection

Acute renal failure

Findings on H&P, Labs, and Imaging

AMS, headache, vomiting and papilledema; labs and a head frequently normal

Headache, coma and focal neurologic deficits; a head with hemorrhage

SOB, chest pain and inspiratory crackles on lung exam; elevated BNP; CXR with cardiomegaly

and pulmonary edema

Chest pain, SOB; elevated troponin; ECG with ischemic changes

Severe chestjback pain; unequal pulses; CXR with wide mediastinum, a chest with dissection

Decreased urine output, hematuria; peripheral edema; urinalysis positive for protein and RBCs ± casts,

acutely elevated BUN and creatinine

AMS, altered mental status; BNP, B-type natri u retic peptide; BUN, blood u rea nitrogen; CT, computed tomography; CXR, chest x-ray;

ECG, electroca rdiogram; RBCs, red blood cel ls; SOB, shortness of breath.

CHAPTER 18