Presentation
Patients will present with a systolic pressure of >180 or diastolic of >120 mmHg
- Hypertensive encephalopathy: headache, vomiting, visual disturbances, seizure and change in mental state
- Hypertensive left ventricular failure: symptoms of decompensated cardiac failure
- Acute aortic dissection: severe ‘tearing’ chest pain that may radiate to the back or jaw, syncope and altered cognition.
History
Does the patient already have a diagnosis of hypertension or renal disease?
Has the patient had recent acute head injury or trauma?
Is the patient experiencing any nausea and vomiting? (think raised intracranial pressure)
Is the patient experiencing any chest pain or acute and severe back pain?
Does the patient report shortness of breath?
Does the patient have any chest pain? SOCRATES
Is the patient pregnant?
Any recreational drug use? (cocaine, amphetamines)
Examination Findings
Generalised neurological symptoms: agitation, delirium, visual disturbances or seixures
Focal neurological symptoms
Fundoscopy: cotton-wool spots, papilloedema, flame haemorrhages
Blood pressure difference between arms of more than >20mmHg is suggestive of dissection
Vital Signs
Severely elevated BP
Tests look for signs on end-organ damage – if any found then refer to intensive care immediately for blood pressure control
Bedside tests
ECG – to look for cardiac damage
Laboratory Investigations
Cardiac enzymes if ACS is suspected
Radiological Investigations
CXR
CT/MRI head in head injury, hypertensive retinopathy or neurological signs
Echocardiogram
Management
Refer to ITU
Overall approach: lower the mean arterial pressured by 10-20% in the first hour and then a further 5-15% over the next 23 hours. Contraindications for the gradual lowering of blood pressure: ischemic stroke, intracerebral hypertension, aortic dissection – seek senior advice
