Definition: Hypertension (diastolic >120)  + end organ dysfunction

History Pearls

Neurological	Visual changes, vomiting, seizures, focal motor or sensory deficits, confusion
Cardiac	Chest pain, abdominal or back pain, palpitations, syncope, dyspnea
Renal	Anuria, hematuria, peripheral edema

Exam Pearls

Neurological	Focal neurological deficits, papilledema, retinal exudates or hemorrhages, AMS
Cardiac	Unequal pulses or BP, pulsatile abdominal mass, new murmurs, carotid bruits, rales
Renal	Peripheral edema

Manifestations of Damage

Neurological	Retinopathy, encephalopathy, SAH, intracranial hemorrhage, acute ischemic stroke
Cardiac	Aortic dissection, AMI or ACS, acute heart failure, pulmonary edema
Renal	Acute renal failure

Special Considerations

• Pre-eclampsia, eclampsia, HELLP in pregnant or postpartum patients 
• Sympathetic crisis in setting of sympathomimetic drug use, pheochromocytoma, MAOI-tyramine reaction, or withdrawal of short acting antihypertensives

References:

1. Johnson, Nguyen, M.-L., & Patel, R. (2012). Hypertension Crisis in the Emergency Department. Cardiology Clinics, 30(4), 533–543. https://doi.org/10.1016/j.ccl.2012.07.011
2. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill.

Why use facial blocks?

• Indications include: laceration repair, acute migraine headaches, zoster outbreaks
• Improved cosmetic healing with regional block compared to infiltrative anesthesia 
• Block provides longer duration of anesthesia compared to infiltrative anesthesia 

How do you perform facial blocks?

• The supraorbital, infraorbital and mental foramen should align with a line drawn vertically through the ipsilateral centered pupil 
• Assess neurovascular status prior to anesthesia especially with trauma 
• Massage area of anesthesia to assist with distribution 
• Complications include: bleeding, hematoma, infection, incomplete anesthesia, vascular puncture, nerve injury, systemic local anesthetic toxicity, ocular injury

Block	Anatomy	Guidance
Supraorbital	Branch of frontal nerve which continues superiorly  Branch of frontal nerve which continues medially	-Supraorbital foramen is 2 cm laterally from nasal aspect of orbital rim-Block both the supraorbital and supratrochlear nerve by directing the needle first cephalad and then medially toward nasal spine
Supratrochlear
Infraorbital	Branch of maxillary nerve which continues medially and caudally	-Infraorbital foramen is below the orbital rim at intersection of pupil and nasal alae -Intraoral approach: inject into the buccal mucosa at canine and direct upward and outward -Extraoral approach: laterally approach foramen until bone is hit, inject local anesthetic
Mental	Branch of mandibular (alveolar) nerve which continues medially	-Mental foramen in line with premolar tooth -Intraoral approach: retract lower lip and insert needle into mucosa of first premolar tooth, inject down and outward  –Extraoral approach: approach foramen laterally

References

Gibbs MA, Wu T. Local and Regional Anesthesia. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. 

Davies T, Karanovic S, Shergill B. Essential regional nerve blocks for the dermatologist: part 1. Clin Exp Dermatol. 2014 Oct;39(7):777-84. doi: 10.1111/ced.12427. PMID: 25214404. https://onlinelibrary.wiley.com/doi/pdf/10.1111/ced.12427 

Sola, C., Dadure, C. D., Choquet, O., & Capdevila, X. (2022, April 26). Nerve blocks of the face. NYSORA. https://www.nysora.com/techniques/head-and-neck-blocks/nerve-blocks-face/   

Alison Jaworski, MD