Section 6

Hypertensive Emergencies

Case Presentation
by Sadiye Yolcu A 68-year-old man with tearing chest pain presented to the
emergency department. He had a history of coronary artery
disease and hypertension. BP: 220/160 mmHg, HR: 105 bpm,
RR: 20/min, T: 37, SpO2: 96% in room air. In the initial
evaluation, airway and breathing were intact. Diastolic murmur
was heard on cardiac auscultation, and pulses were positive in
all extremities. He has a normal mental state (GCS 15) and no
lateralized motor deficit. A difference in systolic blood
pressure was measured between upper extremities (220/160
vs. 180/140 mmHg). ECG showed nonspecific ST-T changes
and sinus tachycardia.

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Introduction urgencies are defined as situations •M a l i g n h y p e r t e n s i o n w i t h o u t
Systemic hypertension is a common requiring actions within 24 hours and yet complication
medical problem. It affects over 1 million do not compromise the risk of developing
• Perioperative hypertension
people worldwide. ER clinicians complications within that period.
commonly encounter this problem. Rapid • Pheochromocytoma,
Hypertensive emergencies include
diagnosis, evaluation, differentiation of
• Sympathomimetic drug use (cocaine,
hypertensive emergencies and • Acute aortic dissection
etc.)
hypertensive urgencies, and appropriate
treatment of these conditions are required • Acute coronary syndrome
Critical Bedside Actions and
to prevent morbidity and mortality.
• Acute heart failure General Approach
The levels above 180 systolic BP and 110 The priority should be given to initial
• Acute renal failure
diastolic BP are considered very stabilization of the patient (C-A-B) as
dangerous which may cause end-organ • Eclampsia other critically ill patients. Depending on
damage such as intracranial bleeding, patients’ symptoms in addition to high
• Hypertensive encephalopathy
aortic dissection, renal failure, etc. Having blood pressure, the cardiac
end-organ damage is the hypertensive • Intracerebral/subarachnoid hemorrhage monitorization, oxygen (if necessary), two
emergency. Having high blood pressure l a rg e b o re I V a c c e s s s h o u l d b e
• Pheochromocytoma, established and blood samples (CBC,
without any signs of end-organ damage
is the hypertensive urgency. Retinal BUN, Cr, coagulation, cardiac markers,
• Sympathomimetic drug use (cocaine
hemorrhage or exudates/papilledema type, and cross-match) sent to the
etc.),
associated with hypertension is defined laboratory. ECG and chest x-ray should
as malignant hypertension. • Stroke be ordered.

Hypertensive emergencies require action Hypertensive urgencies include Lowering BP should be balanced with the
within one hour to abolish the risks of level of BP, patient’s symptoms as well as
• Diastolic tension ≥140 mmHg without
developing complications. Hypertensive harm-benefit situation.
complication
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Differential Diagnosis Each of these hints was g i v e n i n t h e s p e c i fic d i s e a s e
The most critical step in the differential diagnosis is the definition chapters. Therefore, we advise you to review those chapters too.
of the hypertensive situation (emergency or urgency). Suspicion
of hypertensive emergencies aligns with hypertension and end- Emergency Diagnostic Tests and
organ damage. Depending on patient symptoms and findings, Interpretation
An electrocardiogram (ECG) and chest X-ray should be
hypertensive emergencies differentials include severe problems
performed. ECG may show arrhythmias, nonspecific ST-T
such as intracranial hemorrhage, ischemic stroke, aortic
changes or obvious acute MI findings. The chest x-ray may give
dissection, acute MI, AAA rupture, heart failure, renal failure, limb
hints about aortic dissection, aneurysm, pulmonary edema.
or organ ischemia, etc. In addition to these end-organ damages,
other differentials (seizure, brain tumor, encephalitis, What is your opinion about the chest x-ray (Image 4.9)?
encephalopathy, drug overdose, etc.) should also be considered.
Bedside ultrasonography may help to diagnose some critical
History and Physical Examination Hints pathologies timely. These are pulmonary edema, aortic aneurysm
The previous medical history of the patient (chronic diseases, or dissection, heart failure, and increased intracranial pressure.
antihypertensive drugs usage, previous end-organ compromise,
What is your opinion about the transthoracic ultrasound here?
etc.) should be taken. Chest pain for myocardial infarction, aortic
dissection, dyspnea for pulmonary edema, headache, mental Blood urea nitrogen (BUN), electrolytes, complete blood count
status, seizure for hypertensive encephalopathy should be asked. (CBC), liver-renal function tests, coagulation parameters, cardiac
enzymes and urine analyses should be checked. BUN and Cr
The patients present mostly with ischemic stroke, pulmonary
may show renal impairment. Hematuria and proteinuria in the
edema, hypertensive encephalopathy, or congestive heart failure.
urine should also be checked.
Therefore, history and physical exam should be focused on these
problems during the initial and secondary evaluation. In the Some patients may require further investigations with CT or MRI
physical examination, measure the blood pressure from both depending on their symptoms and findings.
arms and assesses the patient for end-organ compromise
(neurologic-ophthalmologic-cardiac). What is your opinion about the CT (Image 4.10)?

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 Image 4.9
Image 4.10

ignore pain medication because some of them require effective

pain control.
Emergency Treatment Options
Medications in specific problems
Initial Stabilization
Aortic dissection
Support C-A-B and stabilize the patient as needed. Cardiac
monitoring, pulse oximetry, oxygen administration, and IV access The aim is to reducing shearing forces by decreasing the heart
required for all hypertensive emergency cases. Key precaution in rate to 60-80 beats/min, and the systolic pressure to 140 mmHg
the control of hypertensive situations is to maintain the balance of and below, then to 120 whether the patient can tolerate. Organ
the benefits of immediate decreases in BP against the risk of a perfusion should be monitored carefully. Na nitroprusside (0.3-0.5
significant decrease in target organ perfusion. Therefore, IV μg/kg) is a potent agent, and the dose can be arisen by 0.5 μg/
agents are preferred because of their titration option. Do not kg/min each time till the maintaining the expected effect on blood
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pressure. Along with Na nitroprusside, mmHg. Nitroglycerin or oral metoprolol Subarachnoidal Hemorrhage
Esmolol (300 μg/kg IV bolus, then 50 μg/ (50-100 mg/12 hrs or IV 5mg on every
The systolic blood pressure and the MAP
kg /min infusion) or labetalol (20-40 mg IV, 5-15 mins up to 15 mg)
should be lower than 160 mmHg and 130
then 20 mg IV on every ten mins, the
Acute Sympathetic Crises mmHg, respectively. Esmolol and
maximum dose is 300 mg) helps to
nicardipine can be used.
control heart rate. If beta blockers are Benzodiazepines are the initial treatment.
contraindicated, verapamil (5-10 mg IV or Nitroglycerine can be considered if Ischemic Stroke
diltiazem 0.25 mg/kg IV can be used. benzodiazepines are not effective.
If the fibrinolytic will be used, the systolic
Phentolamine is another choice (5-15 mg
Acute Hypertensive Pulmonary Edema blood pressure should be lower than
IV).
185/110 mmHg. If the patient will not take
The blood pressure shouldn’t be
Acute Renal Failure a fibrinolytic treatment, then it is
decreased by more than 20-30%. The
important to maintain the BP lower than
first choice is nitroglycerin (5-100 μg/min The blood pressure decreased up to 20%
220/120 mmHg. Nitroglycerin and
IV infusion). Start with 5 μg/min; then it if it is higher than 180/110 mmHg.
nicardipine can be used.
can be increased up to 200 μg/min by Nicardipine, labetalol, or fenoldopam is
increasing 10 μg on every five mins. recommended agents. Hypertensive Encephalopathy
Enalaprilat (0.625-1.25 mg IV in 5 mins
every 4-6 hours) and nicardipine 5 mg/hr Intracerebral Hemorrhage The first agent is Na nitroprusside and
IV infusion, if no control in 15 mins 2.5 followed by labetalol, nicardipine,
The mean arterial pressure (MAP) should
mg/hr dose can be added on every 15 fenoldopam. The systolic blood pressure
be decreased to130 mmHg if the patient
mins). shouldn’t be decreased by more than
has increased intracranial pressure
25% of the total. A 160-170 mmHg
Acute Coronary Syndrome findings. If no suspicion of increased
systolic blood pressure is expected in
intracranial pressure, the MAP can be
first 2-3 hours.
Maximum 20% of the blood pressure decreased to 110 mmHg or the systolic
should be acutely decreased if the blood pressure to 150-160 mmHg.
systolic blood pressure is higher than 160 Esmolol and labetalol can be used.

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Asymptomatic Situations Discharge Criteria
Hypertensive urgencies (Absence of end-organ damage
Oral antihypertensives (hydrochlorothiazides 25 mg/day,
symptoms and findings, known to have hypertension, reversible
Metoprolol 25 mg/day, angiotensin receptor blockers, ACE
causes, etc.)
inhibitors) should be given in the ED and prescribed to the
patients whose systolic blood pressure is higher than 180-200 Referral
mmHg and the diastolic blood pressure higher than 110/120 Patients should refer to their primary care physician or
mmHg. hypertension clinic in 7 days.

Pediatric, Geriatric, and Pregnant Patients

In pregnant patients who have underlying hypertension may
References and Further Reading, click here
present with severe preeclampsia, stroke, pulmonary edema, fetal
decompensation, etc. IV hydralazine and oral nifedipine are
equally effective in pregnant patients. In the pediatric population,
the hypertensive emergency with end-organ effects requires
immediate, and gradual decreasing of the BP. Metoprolol is
effective and safe in the pediatric population.

Disposition Decisions
Admission Criteria
All patients with hypertensive emergencies, signs of end-organ
damage are admitted to the intensive care or high dependency
care unit.

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