Hypertensive Problems - Approach In The Emergency Room

Bear the following points in mind when managing a hypertensive patient in the Emergency Department:
• Most patients with hypertension are asymptomatic.
• Hypertension is an important risk factor for cardiovascular disease and stroke.
• Most patients found to be hypertensive in the ED do not require any immediate intervention or treatment, but do require careful followup — usually by their GP.
• Never intervene on the basis of a single raised BP measurement in the absence of any associated symptoms and signs.

Approach
Approach patients found to be hypertensive as follows:
• Those with no previous history of hypertension, and no other concerns or history of other conditions (eg diabetes, peripheral vascular disease, IHD, or stroke) — arrange follow-up and monitoring with GP.
• Those known to be hypertensive already on treatment — arrange follow-up and monitoring with GP.
• Those displaying evidence of end organ damage (eg LV hypertrophy, retinal changes, renal impairment) — refer to the medical team.
• Those with hypertension associated with pain, vasoconstriction (eg acute pulmonary oedema) or stroke — treat underlying cause where possible. Do not intervene in stroke associated hypertension except under the direction of a neurologist or stroke specialist.
• Those with hypertension directly associated with symptoms or signs — contact the medical team and consider whether intervention is appropriate.


Mild/moderate hypertension (diastolic 100–125mmHg)

• Ascertain if the patient has a past history of hypertension and is taking drug therapy for this. 
• Examine for retinal changes and evidence of hypertensive encephalopathy. 
• Investigate as appropriate (U&E, urinalysis, CXR, ECG).
• Further management will depend upon the BP and the exact circumstances.
• If the BP is moderately elevated (ie diastolic BP: 110–125mmHg) and the patient is symptomatic, refer to the medical team. 
• If the patient is asymptomatic with normal examination and renal function, he/she may be suitable for GP follow up.

Severe hypertension (diastolic > 125mmHg)

• Patients with a diastolic BP > 125mmHg require urgent assessment. 
• Search for evidence of hypertensive encephalopathy : headache, nausea, vomiting, confusion, retinal changes (haemorrhages, exudates, papilloedema), fits, focal neurological signs, decreased conscious level. 
• Ask about recent drug ingestion (eg ecstasy or cocaine ).

Investigations

• Insert an IV cannula and send blood for U&E, creatinine, and glucose. 
• Obtain a CXR and ECG, and perform urinalysis. 
• If there is decreased conscious level, focal signs, or other clinical suspicion that the hypertension may be secondary to stroke or intracranial haemorrhage, arrange an emergency CT scan.

Management

• Refer patients with a diastolic pressure > 125mmHg or evidence of hypertensive encephalopathy to the medical team. Resist commencing emergency treatment until consultation with an expert. There is a significant risk of complications (stroke or MI) if the BP is reduced rapidly.

It may be appropriate to commence oral antihypertensive therapy using a B-blocker (eg atenolol or labetalol) or calcium channel blocker (eg nifedipine).

• If treatment is appropriate, commence an IV injection of sodium nitroprusside, labetalol or GTN with continuous BP monitoring via an arterial line and admit to high dependency unit (HDU) or ICU. Sodium nitroprusside has a very short half-life ( appx 1–2min) and acts as a vasodilator of both

arterioles and veins. IV labetolol may be preferred if aortic dissection or phaeochromocytoma are suspected.

• Beta-blockers are contraindicated in hypertension caused by cocaine, amphetamine or related sympathomimetic drugs , since B-blockade may cause unopposed A-adrenergic activity with paradoxical hypertension and decreased coronary blood flow.

Hypertension in pregnancy

Hypertension may be part of pre-eclampsia or eclampsia

Pre-eclampsia is diagnosed with 2 or more of: hypertension ( > 140/90), proteinuria and oedema. This can be associated with haemolysis, elevated liver function tests (LFTs), low platelets (HELLP syndrome).

Check urine for protein and check blood for FBC, LFT, platelets, and coagulation screen. 

Call for senior obstetric help. 

Eclampsia is diagnosed with the onset of grand mal seizures after 20 weeks gestation, and carries a significant mortality rate.