A hypertensive emergency is an acute, marked elevation in blood pressure that is associated with signs of target-organ damage. These can include pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia.

2. HYPERTENSIVE
EMERGENCY

3. CASE
•A 65year-old man with a 2-month history of
progressive headache presented to the
emergency department with nausea,
vomiting, visual disturbance, and confusion
for 8 hours. He denied fever, weakness,
numbness, shortness of breath, and flulike
symptoms.

4. PAST MEDICAL & SURGICAL HX
He had significant medical history of hypertension and was
on a β-blocker in the past, but a year ago, he stopped
taking medication due to an unspecified reason. The
patient denied any history of tobacco smoking, alcoholism,
and recreational drug use AND NO SIGNIFICANT SURGICAL HX
The patient had a significant family history of hypertension
in both his father and mother. Physical examination was
unremarkable, and at the time of triage, his blood pressure
(BP) was noted as 210/123 mm Hg, equal in both arms.

5. MX
- LABETALOL 10-20 MG (0.25MG/KG FOR 80KG PATIENT ) I/V OVER 2
MINTS
OR
-INJ. HYDRALAZINE 10MG I/V SLOWLY INFUSION MAXIMUM 20MG
OVER 4 TO 6 HOURS

6. WORK -UP
• All Base Lines
• Urinanalysis:hematuria,proteinuria,RBCs,RBC casts.
• Toxicology,Pregnancy,endocrine causes.
• Imaging:Chest X-ray,Head MRI
• EKG,cardiac enzymes

7. LAB & RADIOLOGICAL FINDINGS
• ECG: EXCEPT LT AXIS DIVIATION NO OTHER FINDING
• Xray Chest:LVH
• All base line are with in normal range.
• Urinelysis:Normal
• MRI:MRI of the brain was performed in the emergency department and
demonstrated multiple scattered areas of increased signal intensity on T2-weighted
and fluid-attenuated inversion recovery (FLAIR) images in both the occipital and
posterior parietal lobes. There were also similar lesions in both hemispheres of the
cerebellum (especially the cerebellar white matter on the left) as well as in the
medulla oblongata. The lesions were not associated with mass effect, and after
contrast administration, there was no evidence of abnormal enhancement.

8. WHAT IS YOUR DIAGNOSIS

9. DIFFERENTIAL DIAGNOSIS OF HTN EMERGENCY
• ACUTE AORTIC DISSECTION
• ACUTE PULMONARY EDEMA
• ACUTE MYOCARDIAL INFARTION
• ACS
• ACUTE RENAL FAILURE
• SEVER PRE-ECLAMSPIA /ECLAMSPIA
• HYPERTENSIVE RETINOPATHY
•HYPERTENSIVE ENCEPHALOPATHY
• INTRACRANIAL HEMORRHAGE
• STROKE
• SYMPATHETIC CRISIS

10. MX OF HYPERTENSIVE ENCEPHALOPATHY
• GOAL OF TREATMENT IS TO DECREASE MAP 20% TO 25% IN THE
FIRST HOUR OF PRESENTATION
• AVOID RAPID BP LOWERING TO PREVENT CEREBRAL HYPOPERFUSION
WHIC MAY LEAD TO ISCHEMIC INFARCTION
• DRUGS OF CHOICE
• LABETALOL : BOLUS : 10 T0 20 MG (0.25MG/KG FOR 80KG I/V OVER
2MINT 40 TO 80 OVER 10 MINTS INTERVALS UPTO 300MG
• NICARDIPINE: CONTINUOUS INFUSION : START AT RATE OF 5MG/H
MAXIMUM DOSE 15MG INCREASE DOSE 2.5MG
• CLEVIDIPINE:INFUSION INITIATE AT 1 TO 2 MG /H

11. DEFINE HTN ACC/AHA
• MEETING ONE OR MORE OF THESE CRITERIA
• A 24 HOURS MEAN OF MORE THEN 125 SBP OR 75 DSBP
• DAYTIME MEAN MORE THEN 130 SBP OR ABOVE 80 DSBP

12. • TYPE OF HTN
• PRIMARY HTN
• SECONDARY HTN
• HTN AFFECTS APPROX 40% OF THE US POPULATIONS
• 1 TO 6% CASE PRESENT TO ED WITH SEVER HTN OR HTN CRISIS
• RISK FACTORS: 1)NON-MODIFIABLE RISK FACTOR
(AGE,GENDER,GENETIC, ETHNICITY)
2)MODIFIABLE RISK FACTORS(OBESITY , SALT INTAKE,
SATURATED SAT, ALCOHOL, SMOKING, STRESS, DM,

13. PATHOPHYSIOLOGY

14. DISCUSIONS

15. HTN CRISIS
• DEFINE: ACUTE ELEVATION OF BLOOD PRESSURE WHERE THE
SYSTOLIC BP MORE THEN 180 AND DSB IS MORE THEN 120
• THERE ARE TWO FORM OF HTN CRISIS
• HTN EMERGENCY : IS HTN CRISIS IN WHICH SBP MORE HTEN 180
AND DSB IS MORE THEN 120 WITH CONCOMITANT END ORGAN
DAMAGE
• END ORGAN OR TARGAT ORGANS (BRAIN , HEART , AORTA, KIDNEY ,
EYE)
• HTN URGENCY :IS HTN CRISIS WITH OUT ORGAN DAMAGE BUT
LEADING TO ORGAN DAMAGE IF NOT MANAGED

16. PRESENTATIONS OF DIFFERENT HTN ER
• AORTIC DISSECTIONS: CHEST PAIN, BACK PAIN , UNEQUAL BP IN
UPPER EXTREMITIES
• ACUTE PULMONARY EDEMA: SOB
• ACUTE MI:CHEST PAIN ,NAUSEA, VOMITING , DIAPHORESIS
• ACS: CHEST PAIN, NAUSEA, VOMITING, DIAPHORESIS
• ACUTE RENAL FAILURE: MAY HAVE SYSTOLIC OR DIASTOLIC
ABDOMINAL BRUIT
• PRE-ECLAMPSIA, ECLAMPSIA: SEIZURES, SOB , HEADACHE, BLURRED
VISSION, EPIGASTRIC PAIN

17. CONT.....
• HTN RETINOPATHY:BLURRED VISSION
• HTN ENCEPHALOPATHY: ALOC, NAUSEA , VOMITING, HEADACHE
• SUBARACHNOID HEMORRHAGE: HEADACHE, FOCAL ND
• SYMPATHETIC CRISIS: ANXIETY , PALPITATION, TACHYCARDIA,
DIAPHORESIS