A hypertensive emergency is severely raised blood pressure, usually above 180/120 mmHg, with new damage to organs such as the brain, heart, kidneys or eyes. The goal is a controlled drop with IV medicine in an ICU, because lowering it too fast can cause a stroke or heart attack.
Key symptoms
- Severe headache, blurred vision or confusion
- Chest pain or pressure
- Shortness of breath, worse lying flat
- Weakness, numbness or trouble speaking
- Nausea, vomiting or seizure
What you find on exam
- Blood pressure in both arms, repeated with the right cuff size
- Neurologic exam: level of consciousness and focal deficits
- Fundoscopy: retinal hemorrhages, exudates or papilledema
- Heart and lungs: crackles, new murmur, unequal pulses that suggest dissection
Tests
- ECG and troponin for heart strain or ischemia
- Creatinine, electrolytes and urinalysis for blood and protein
- Blood count and smear if hemolysis is suspected
- Chest X-ray; CT head if neurologic signs; CT angiography if dissection is suspected
Treatment basics
- Admit to the ICU with an arterial line and continuous monitoring
- IV infusion of nicardipine, clevidipine or labetalol
- Lower mean pressure by no more than 25 percent in the first hour, then toward 160/100 mmHg over the next hours
- Faster targets for aortic dissection (systolic under 120 mmHg), severe preeclampsia or pheochromocytoma crisis
- Find and treat the cause: missed medicines, stimulant use, kidney disease
Red flags
- Tearing chest or back pain with unequal arm pressures
- New confusion, seizure or one-sided weakness
- Pulmonary edema, or new symptoms when pressure drops too fast
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Sources: NASEMSO National Model EMS Clinical Guidelines; NCCPA PANCE Content Blueprint; AHA Scientific Statement, Measurement of Blood Pressure in Humans (Hypertension, 2019). Written by Making Synapses. Making Synapses is not affiliated with these organizations.