Download Acute hypertensive crisis

 Acute hypertensive crisis
Recommend
 Aim to reduce blood pressure by no more than 25% within the first 2 hours, then toward 160/100
mm Hg within 2 to 6 hours [6]
 Avoid lowering blood pressure too rapidly as this can cause decreased blood supply (ischaemia)
to kidney, heart or brain [6]
Background
 Severe hypertension (often defined as systolic blood pressure of ≥ (greater than or equal to)180
mmHg and/or diastolic blood pressure ≥ (greater than or equal to) 120 mmHg can produce a
variety of acute, life threatening complications such as encephalopathy, acute heart failure,
aortic dissection, subarachnoid haemorrhage, retinal haemorrhages, papilloedema, and acute
kidney failure. These are hypertensive emergencies.
 BP cuff size is critical and must be appropriate to the arm size
Related topics:
 Acute coronary syndrome, page 79
 Acute pulmonary oedema, page 87
 Hypertension, pages 92, 334
TIA / Stroke, page 235
 Pregnancy induced hypertension (pre-eclampsia), page 403
Acute post streptococcal glomerulonephritis, page 537
 Irukandji syndrome, page 214
1.
May present with:
 Dizziness / feeling faint
 Confused, drowsy, unconscious, fitting
 Headache, visual disturbance
 Chest pain (angina / heart attack)
 Breathlessness / heart failure
 Papilloedema, retinal haemorrhages on looking into the back of the eyes (fundoscopy)
 Haemorrhagic stroke, (see TIA / Stroke)
 Asymptomatic
2.
Immediate management:
DRABC Resuscitation / the collapsed patient
3.
Clinical assessment:
 Obtain emergency patient history - previous medical history, including previous blood pressure
readings and episodes of acute hypertensive crisis
 Current medications
 Perform standard clinical observations with particular note:
 of blood pressure (with correct size cuff), take BP lying and standing and on both arms
 conscious state (see Glasgow coma scale or AVPU)
 urinalysis, capillary BGL, height and weight (if possible)
 urine pregnancy test (with consent) if female of childbearing age (12 – 52 years). Pregnancy
should be considered as a cause in any woman of childbearing age who presents with
symptomatic hypertension (see Pregnancy Induced Hypertension (pre-eclampsia))
 do 12 lead ECG and fax to MO
 take blood for electrolytes
 Perform physical examination

auscultate the chest for air entry and added sounds (crackles or wheezes)

palpate the abdomen for enlarged liver

inspect and palpate the ankles, shins and sacrum for oedema
4.
Management:
The patient is conscious with no evidence of complications.
 Insert IV cannula
 Administer sublingual glyceryl trinitrate (GTN)
 Consult MO who may advise:
 GTN patch or infusion for patients
 Labetalol IV
 Hydralazine IV or IM– use limited to pregnant women
 oral treatment with antihypertensive such as metoprolol, ace-inhibitor
 evacuation/hospitalisation
 Rapid reduction in BP is not recommended. Aim to lower the BP but not to less than systolic BP
of 160 and diastolic BP of 110. Be wary of lowering the BP if there is any acute neurological
deficit
Schedule
3
Glyceryl Trinitrate (GTN)
DTP
IHW / NP
Authorised Indigenous Health Workers may proceed
Nurse Practitioners may proceed
Route of
Recommended
Form
Strength
Duration
Administration
Dosage
Tablet
0.6 mg
Sublingual
Adults only:
Stat
0.3 mg (½ tablet)
Spray
400
Sublingual
Adults only:
Stat
micrograms
One to two sprays
per dose: in
14.7mL
Provide Consumer Medicine Information if available: do not give GTN if has taken Viagra® in
the last 24 hours
Management of Associated Emergency: Consult MO
5.
Follow up:
 If patient not evacuated/hospitalised, review next day
 Next MO clinic
 Hypertension maybe due to other conditions eg intracranial haemorrhage, raised intracranial pressure,
chronic kidney failure – manage as per MO directions
 Offer advice and information re lifestyle aspects contributing to hypertension (alcohol, obesity, lack of
exercise) and how compounded by others (smoking, increased blood lipids, diabetes, family history)
to greatly increase risk of ischaemic heart disease (angina/heart attack) and cerebrovascular disease
(TIA/Stroke). See Hypertension)
6.
Referral /Consultation:
 Consult MO on all occasions BP 160/110
 Review next day and see next MO clinic on all occasions BP 140/90