by Dr. Sarah Perelman M.D.
Today’s case from the EM Daily archives involves one of the rare patients where you DO want to acutely treat elevated blood pressure with intravenous agents….
HPI
- 48 year old male with PMH HTN presents with blurry vision for 2.5 hours
- Patient was using the computer tonight, could not see where the icons were on his desktop, could still see light/colors.
- He has no pain in his eyes
- Also reports dyspnea on exertion for 2 days. No headache, no chest pain, no abdominal pain
- He has not had his anti-hypertensives (he reports he is on 5 different medications) for about 1.5 weeks
Physical Exam
T 98.3 BP 290/120, HR 118, RR 18, SpO2 99%
- Patient is awake, alert, conversant, appears well and in no distress
- Neuro: Visual acuity 20/200 OS, OD, OU Normal visual fields Normal pupillary exam Normal extraocular movements Otherwise normal cranial nerve exam Normal strenght in extremities , no pronator drift, normal finger to nose
- Cardiac: tachycardic, normal S1/S1, no murmurs/rubs/gallops
- Pulm: clear to auscultation bilaterally
- Abdomen: soft, nontender, nondistended
Differential Diagnosis
- Hypertensive emergency with elevated BP and evidence of end organ damage (decreased visual acuity, evidence of pulmonary edema on bedside US)
- Sympathomimetic toxicity (hypertension, tachycardia), though patient reports no ingestions of medications or drugs
- Thyrotoxicosis
- CVA given visual changes, however with no focal visual deficits (no visual field cut, decreased acuity is symmetric bilaterally)
Initial ED Management
- Arterial line place – IV nicardipine started, with goal SBP 210s (25% reduction in the first hour)
- Bedside lung US performed which demonstrates numerous B lines consistent with evolving pulmonary edema
Labs/Imaging –
- Hb 6.1, PLT 142, WBC 5.92 – Na 147, K 3.7 – Cr 15.03 (last level in chart 3.95 7 years ago) – HS troponin 223 – pro-BNP 26,930
- CT Head with 3 small, distinct areas of intraparenchymal hemorrhage
Further Management
- Repeat neurologic exam performed and is unchanged
- Neurosurgery consulted, recommend BP goal under SBP 160
- Repeat CTH in 4 hours: unchanged
- Patient admitted to ICU for IV nicardipine, continuous BP monitoring, and q1 hour neuro checks
Pearls
- Hypertensive emergency is acute SBP over 180 with evidence of organ dysfunction
- Not every patient with SBP over 180 requires emergency BP control
- In this patient: decreased visual acuity, pulmonary edema, elevated troponin and proBNP, renal failure, and intraparenchymal hemorrhage = hypertensive emergency
- In managing hypertensive emergency, SBP should not be lowered by more than 25% in the first hour to prevent causing hypoperfusion and cerebral ischemia
- Continuous BP monitoring via arterial line is important to carefully titrate medications
- Nicardepene is an easy to titrate CCB which may be the ideal agent for the treatment of hypertensive emergency
- Indications for emergent dialysis (AEIOU – acidosis, electrolytes, intoxication, overload, uremia): critical metabolic acidosis, refractory or rapidly increasing hyperkalemia, life threatening intoxication with substance that is able to be removed with HD, volume overload, complications of uremia (pericarditis, neuropathy, encephalopathy)
