Emergency Medicine/Hypertensive Emergencies

=Hypertension=

Hypertension
Hypertension, as defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), is defined as the systolic blood pressure (SBP) > 140 mmHg and/or diastolic blood pressure (DBP) > 90 mmHg. In order to diagnose a patient with hypertension, the blood pressure must be above these levels for the average of at least two separate readings in a seated patient on at least two separate office visits.

JNC 7 defines two stages of hypertension:
 * Stage I: SBP 140-159 mmHg and/or DBP 90-99 mmHg
 * Stage II: SBP >= 160 mmHg and/or DBP >= 100 mmHg

Hypertensive Urgency
Hypertensive urgency is defined as severe hypertension without acute evidence of target organ damage/dysfunction (CNS, cardiovascular, renal).

Hypertensive Emergency
Hypertensive emergency is defined as severe hypertension with evidence of acute target organ damage/dysfunction. Treatment always requires IV medication and reduction of blood pressure within one hour.
 * Note: a patient does not necessarily have to carry a previous diagnosis of hypertension to present with hypertensive emergency!

Etiology
In most cases, the exact cause of hypertension is never found, and the hypertension is said to be "essential". There are, however, several reversible and correctible causes that should be searched out and eliminated if at all possible.

These include:
 * Drug use
 * OTC sinus preparations
 * PCP
 * Amphetamines
 * Cocaine
 * Oral contraceptives
 * Drug withdrawals
 * Beta blockers
 * Alpha2 agonists
 * Renal Artery Stenosis
 * Pheochromocytoma
 * Aortic coarctation
 * Cushing Syndrome/Disease
 * Pre-eclampsia/Eclampsia
 * Hyperaldosteronism

History
Historical account should focus on the presence or absence of organ damage/dysfunction (see below), any previous history of hypertension, current medications, and ruling in/out the above etiologic factors.

Specifically ask about:
 * Back pain - Aortic dissection
 * Chest pain - Myocardial infarction or ischemia
 * Dyspnea - Pulmonary edema, CHF
 * Neurologic symptoms - headache, visual disturbances, altered level of consciousness, seizures
 * Symptoms of Encephalopathy

Examination
Vital signs: Should be monitored every 5–10 minutes if hypertensive emergency is considered.

General: Level of consciousness, fluency of speech

HEENT: Funduscopic exam should be performed looking for papilledema, new exudates, and flame hemorrhages.

Cardiovascular: Look for signs of long standing hypertension and acute cardiovascular dysfunction
 * Heaves
 * Displacement of the PMI
 * Carotid bruits
 * Elevated JVP
 * Peripheral edema

Pulmonary: Evaluate for signs of CHF
 * Crackles
 * Wheezes
 * Accessory muscle use/retractions

Abdomen: Assess for bruits or pulsatile masses

Neurologic: Look for signs of hypertensive encephalopathy
 * Altered level of consciousness
 * Acute confusional states/delirium
 * Visual field deficits
 * Focal deficits, either centrally or peripherally

Imaging/Lab Studies
BMP, CBC, UA, Tox studies (if indicated)

EKG should be performed if chest pain or dyspnea is present

Chest radiographs may be indicated if there is chest pain or dyspnea

Head CT is indicated if there are focal neurological findings

Hypertensive Urgency
Treatment of hypertensive urgency involves reducing the blood pressure to normal or near-normal levels within 24 to 48 hours. These patients, who do not have any objective evidence of end-organ damage, may be discharged on oral anti-hypertensives with close follow-up at their primary physician's office within the next 2–3 days.

Hypertensive Emergency
Hypertensive emergency requires rapid BP lowering and admission to a step-down unit or the ICU. General principles include reducing the mean arterial pressure (MAP) by 20% in 1–2 hours with IV anti-hypertensives, including nitroprusside, nitroglycerin or IV beta-blockers. Afterwards, the blood pressure should be brought to 160/100 over the next 6–8 hours.