Tuesday Advanced Cases & Procedure Pearls

Critical Cases – Hypertensive Emergency!

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….


  • 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


  • 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)

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