CE Article: Hypertensive Urgencies and Emergencies

Mason and his partner Jen, both paramedics, are dispatched to a local pharmacy for an “unknown medical problem.” They arrive to find a 44-year-old male, Jim, sitting comfortably at a blood pressure machine in no apparent distress. The pharmacist tells the crew Jim used the machine and recorded a blood pressure of 190/118 mmHg. The pharmacist had him repeat the procedure, and the second blood pressure was 194/120 mmHg. The pharmacist then called 9-1-1.

Jim tells Mason and Jen that he came to the pharmacy with his wife and used the blood pressure machine “for the hell of it, just to see what it was.” He has no complaint, and when asked he denies any chest pain or discomfort, difficulty breathing, dizziness, weakness, syncope, abdominal or back pain, nausea, vomiting or headache. He is alert and oriented to person, place, time and event. His vital signs are: HR, 64/min., strong and regular; RR, 12/min., with good tidal volume; BP, 192/120; SpO₂, 98% on room air. The clinical exam is unremarkable, and all findings are normal. The cardiac monitor shows a normal sinus rhythm, and the 12-lead ECG shows no acute ST-segment changes. Jim reports he has no past medical history, takes no medications and has no allergies. The pharmacist tells Jim, “You really need to go to the emergency room and get that blood pressure checked out.

Jim looks up at Mason and Jen and asks, “Do I really need to go to the emergency room? What do you think?”

Epidemiology

Hypertension is a leading risk factor for cardiovascular disease and a significant cause of morbidity and mortality. In the period from 2003–2010, the CDC estimated the overall prevalence of hypertension among adults in the United States was 30.4%, encompassing an estimated 66.9 million persons, or nearly a third of the U.S. population.^1,2 Of these persons, an estimated 35.8 million (53.5%) did not have their blood pressure under control.¹ Of these persons with uncontrolled hypertension, an estimated 14.1 million (39.4%) were not aware of their hypertension, an estimated 5.7 million (15.8%) were aware of their hypertension but not receiving pharmacologic treatment, and an estimated 16.0 million (44.8%) were aware of their hypertension and were being treated with medication.¹

It may seem logical to conclude that those persons with uncontrolled hypertension most likely lack access to a regular source of healthcare and/or health insurance. On the contrary, of the 35.8 million U.S. adults with uncontrolled hypertension, 89.4% reported having a usual source of healthcare, and 85.2% reported having health insurance.¹

The World Health Organization estimated that in 2008, worldwide, approximately 40% of adults aged 25 and older had been diagnosed with hypertension, a percentage equal to about 1 billion persons.^3,4 The WHO also estimates that complications of hypertension account for about 9.4 million deaths worldwide every year.⁵

The incidence of hypertensive emergencies has declined from 7% to 1% of patients with hypertension.⁶ Given that hypertension is such a ubiquitous problem worldwide, and with more than 50% of patients (at least in the U.S.) suffering from uncontrolled hypertension, it is within reason to expect that EMS providers will frequently encounter patients with elevated blood pressures. The overwhelming majority of these patients will present asymptomatically (they will not have signs and/or symptoms of target-organ damage), and their elevated blood pressure will often resolve without treatment after a few hours in the emergency department.^7,8

For patients who are symptomatic, however, uncontrolled elevations in blood pressure are true medical emergencies that require rapid intervention in the ED. It is therefore important to understand the disease of chronic hypertension and, perhaps more important, episodes of acute and uncontrolled elevations in blood pressure so that we, as prehospital care providers, can better stratify these patients into low- and high-risk groups that may or may not require transport to an ED for evaluation and treatment.

As we will discuss, it is reasonable to say that not every patient who presents with hypertension is at high risk of morbidity and mortality and absolutely requires evaluation and treatment at an ED. This is not to say EMTs and paramedics should talk patients out of going to EDs for evaluation. Rather, we will strive to give prehospital care providers a better understanding of the risks involved with acute hypertension so they can better work with their patients to find a solution that is safe, reasonable and responsible for everyone involved. This month’s article discusses the topic of acute hypertension, hypertensive urgency and hypertensive emergencies in an effort to help EMS providers better understand these illnesses and help patients make the best decisions regarding their transport and care.

Definitions and Terms

While most EMS providers will describe a “normal” blood pressure as 120/80 mmHg, the concept of what is “normal” and what constitutes hypertension is constantly evolving. That being said, the most widely accepted definition of hypertension describes it as:⁹

• A systolic blood pressure greater than or equal to 140 mmHg, or a diastolic blood pressure greater than or equal to 90 mmHg, or taking antihypertensive medication; or

• Having been told at least twice by a physician or other health professional that one has high blood pressure.

Severe hypertension (hypertensive crisis) in the adult is defined as a systolic blood pressure greater than or equal to 180 mmHg and/or a diastolic blood pressure greater than or equal to 110 mmHg.¹⁰ The term hypertensive urgency (a.k.a. severe asymptomatic hypertension) is used to describe the relatively asymptomatic patient with a blood pressure in the “severe” range but without signs or symptoms of acute target-organ damage.⁹ Patients with hypertensive urgency may present with severe headache, shortness of breath or anxiety.⁹

A hypertensive emergency exists when a patient with a significantly elevated blood pressure (which may or may not meet the criteria for severe hypertension) exhibits signs and/or symptoms of acute target-organ injury and dysfunction.⁹ Examples of target organs include the brain, eyes, heart, aorta, lungs and kidneys. Specific emergencies that are examples of acute target-organ injuries are listed in Figure 1.

Two broad and distinct populations of patients can be predicted: those patients with poorly controlled chronic hypertension, and those patients presenting with elevated blood pressure and no prior history of hypertension. Patients with a history of hypertension may experience increases in blood pressure for a number of reasons. They may be noncompliant with their medications, receiving inadequate medical management or experiencing an exacerbation of their disease. In addition, concomitant use of other medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, decongestants, appetite suppressants, over-the-counter stimulants, oral contraceptives and tricyclic antidepressants can contribute to increases in blood pressure.¹¹

Patients experiencing an episode of high blood pressure without a prior history of hypertension frequently present to EMS and the ED. In such cases the patient typically has their elevated blood pressure identified during the obtaining of routine vital signs during a visit to their physician, a community health screening event or via an automated blood pressure cuff at home or in the community. A blood pressure is typically not considered “elevated” until it is so over 2–3 consecutive sets of vital signs.

Hypertensive Urgency

Patients with hypertensive urgency will have an elevated blood pressure and can present asymptomatically or with relatively minor symptoms. Symptoms are generally nonspecific and include headache, dizziness, dyspnea, anxiety, atypical chest pain, generalized weakness or numbness, and vague visual disturbances.¹¹

How should the EMS provider approach the patient with hypertensive urgency? Do all of these patients require transport to the ED? Do they require treatment in the field by EMS, and will they receive treatment in the ED?

Before discussing how the EMT or paramedic should approach the patient with hypertensive urgency, it is useful to consider how the ED physician may approach these patients. The American College of Emergency Physicians in 2013 published a clinical policy that addresses this issue, “Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure.¹² In this policy, two critical questions are answered that can help the prehospital care provider deal with hypertensive urgency in the field.

Question #1—In ED patients with asymptomatic, markedly elevated blood pressure, does screening (ECG, urinalysis, serum creatinine) for target-organ injury reduce rates for adverse outcomes? Two recommendations were made:

• In patients with asymptomatic, markedly elevated blood pressure, no screening for target-organ injury is required.

• In select patient populations (e.g., patients with anticipated poor follow-up), screening a serum creatinine level may identify kidney injury that affects disposition, such as hospital admission.

So according to the ACEP guidelines, the patient with asymptomatic, markedly elevated blood pressure does not require screening exams such as an ECG to assess for myocardial ischemia or urinalysis or serum creatinine tests to assess for renal insufficiency or failure. The patient should have follow-up arranged with a physician in the outpatient setting to determine if chronic hypertension exists. Patients who cannot be trusted to follow up with a physician (the homeless, patients with psychiatric illness, etc.) should have a screening exam that may identify kidney injury. Screening will help identify the patient, and subsequent admission will get them the medical attention they require.

Question #2—In patients with asymptomatic, markedly elevated blood pressure, does ED medical intervention (start treating, prescribe meds, etc.) reduce the rates of adverse outcomes? Two recommendations were made:

• In ED patients with asymptomatic, markedly elevated blood pressure, routine ED medical intervention is not required.

• In select patient populations (again, poor follow-up), emergency physicians may (not must; physicians have an option) treat markedly elevated BP in the ED and/or initiate therapy for long-term control.

• Patients with asymptomatic, markedly elevated blood pressure should be referred for outpatient follow-up.

So according to the ACEP guidelines, the patient with asymptomatic, markedly elevated blood pressure does not require immediate medical intervention to lower their blood pressure. In fact, it’s known that the rapid lowering of markedly elevated blood pressure in the asymptomatic patient does not improve morbidity and mortality and has the potential to do harm.^6,13–15 And, a significant number of patients who present to the ED with high blood pressure will have their pressures spontaneously decrease, without intervention, during the 60–90 minutes after the initial measurements in the ED.^7,16 If an emergency physician wants to simply arrange follow-up care for the patient, that is fine. An option to begin medical treatment for acute hypertension is offered for those patients who cannot be trusted to adhere to follow-up instructions. This gives the patient a better chance of receiving the long-term care they require.

The question is, how can we apply this information in in the prehospital environment? First, it’s important to appreciate that this information should not be used to dissuade any patient who requests transport to an ED for evaluation from doing so. Rather, if a patient with asymptomatic hypertension (hypertensive urgency) asks, “Do I need to go to the hospital?” or refuses to go to the ED for evaluation, the EMT or paramedic is in a better position to offer informed advice.

If a patient presents with an elevated blood pressure and no complaint, it is reasonable for that patient to not go to the ED for evaluation, if that is their decision, as long as they understand the risks and seek immediate follow-up care with their personal physician. Potential risks of not receiving evaluation by a physician include injury or death from heart attack, stroke, aortic dissection or renal failure. For patients who cannot immediately see their personal physician, transport to the ED will allow for physician evaluation, possible treatment and the arranging of follow-up care.

For patients who may not be able to comply with the need for follow-up care, every effort should be made to convince them to consent to transport to the ED for evaluation. If a patient is not competent to make decisions, then they should be transported under the auspices of implied consent. Basic life support (BLS)-level care during transport is appropriate for the patient with elevated blood pressure who has no complaint (symptoms).

Recall that patients with hypertensive urgency may also present with what the ACEP guidelines describe as “minor” symptoms such as dizziness, dyspnea or atypical chest pain. Keep in mind that these symptoms are considered “minor” in the setting of hypertensive urgency because they are being compared to the symptoms associated with the target-organ failure characteristic of hypertensive emergency. It is the opinion of these authors that prehospital care providers should make every effort to convince these patients to seek evaluation by a physician in an ED. While symptoms such as dizziness, dyspnea or atypical chest pain may indeed be “minor” in the setting of acute hypertensive urgency, they can also be associated with numerous life-threatening emergencies.

Advanced life support (ALS)-level care during transport would be prudent. Administer oxygen via a delivery device sufficient to maintain an SpO₂ above 94%. In most cases a nasal cannula will be sufficient to deliver adequate oxygen if it is required. Cardiac monitoring should be initiated, and a 12-lead ECG performed if symptoms suggest acute myocardial infarction. Peripheral intravenous access should be established, and a saline lock placed. Unless your protocols say differently, no attempt should be made to lower the blood pressure in the patient with hypertensive urgency in the prehospital environment.

Hypertensive Emergency

As discussed previously, most patients with markedly elevated blood pressure have no acute target-organ injury and do not require rapid intervention and antihypertensive therapy. In contrast, patients having a hypertensive emergency require rapid intervention. In the prehospital setting this centers on maintaining adequate airway, breathing and circulation status and will not include antihypertensive therapy.

For all of the emergencies discussed below, routine ALS medical care starts with airway maintenance. If the patient cannot protect their airway, perform manual airway maneuvers (head-tilt chin-lift and/or jaw thrust) in conjunction with the use of a BLS airway adjunct such as a naso- or oropharyngeal airway. Consider use of a supraglottic airway or endotracheal intubation if the patient cannot protect their airway.

Administer oxygen via a delivery device sufficient to maintain an SpO₂ of at least 94%. If breathing is adequate, consider the use of a nasal cannula for oxygen administration. If breathing is inadequate, ventilation should be assisted or provided with a bag-mask device. Place all patients on a cardiac monitor and monitor their cardiac rhythm throughout transport. Establish IV access, place a saline lock and determine a blood glucose level. Any additional treatment options will be discussed below. All patients with hypertensive emergency should have their heads placed midline and elevated 30 degrees in an effort to reduce cerebral hypertension.

The most frequent target organs affected by hypertensive emergency, in descending order of incidence, are the brain, heart, kidneys, aorta and eyes.¹¹ It is through dysfunction of these target organs that hypertensive emergency is often identified.

Neurologic Emergencies

Neurologic emergencies that can occur with hypertensive emergencies include ischemic stroke, hemorrhagic stroke (both intracerebral and subarachnoid) and hypertensive encephalopathy. Signs and symptoms of stroke include hemiplegia or hemiparesis, slurred speech, facial droop (all components of various stroke scales), altered mental status, headache, decreased reflexes, altered gait, vertigo, aphasia and dysarthria. Hypertensive encephalopathy occurs secondary to the cerebral edema that can happen with marked elevations in blood pressure. Signs and symptoms include severe headache, nausea, vomiting and altered mental status. Hypertensive encephalopathy is often a diagnosis of exclusion, as the symptoms resolve after the blood pressure is lowered.

Patients suffering from stroke or hypertensive encephalopathy should receive routine ALS care. If stroke is suspected, the time of onset of symptoms should be determined and the patient transported to a stroke center. Hypertension in the presence of neurological symptoms should never be treated until a CT scan is completed in an ED. It is imperative to understand if the patient is experiencing a hemorrhagic stroke, ischemic stroke or other etiology prior to blood pressure management, as each will have its own unique blood pressure target, a discussion that is beyond the scope of this article.

Cardiac Emergencies

Two common cardiac emergencies associated with hypertensive emergency are acute heart failure and acute coronary syndrome (ACS). Acute heart failure occurs secondary to the increased afterload that occurs with hypertension. Chronic hypertension is a primary risk factor for the development of heart failure. Signs and symptoms associated with heart failure include difficulty breathing, acute pulmonary edema (rales or crackles upon auscultation) and hypoxia when the left side of the heart is involved, and jugular venous distention and peripheral edema with the right.

In addition to routine ALS care, patients exhibiting signs of pulmonary edema should receive continuous positive airway pressure (CPAP), which will both decrease the work of breathing as well as help resolve pulmonary edema. Nitroglycerin can be administered sublingually, intravenously or transdermally, as protocol allows, in an effort to increase venous capacitance, thereby reducing preload, and reduce afterload. Avoid the use of nitrates in patients who have used erectile dysfunction medications such as Cialis, Viagra or Levitra in the previous 24 hours.

ACS can also occur secondary to the increased afterload that occurs with hypertension when the heart must increase its workload to compensate for the resistance to blood flow. In addition to routine ALS care, all patients with suspected ACS should receive a 12-lead ECG. If ACS is suspected, only administer oxygen if the room air oxygen saturation is less than 94% or if there is respiratory involvement. Titrate oxygen flow to achieve a saturation of greater than 94%.¹⁷ Administer aspirin 160–325 mg, nitroglycerin sublingual or spray, and morphine IV as long as no contraindications exist. Patients with suspected ACS should be transported to a cardiac center.

Renal Emergencies

Markedly elevated blood pressure can cause damage to the arterioles in the kidneys, resulting in acute injury and eventually failure. Signs and symptoms include hematuria and increased serum creatinine levels. In the prehospital environment, routine medical care is provided.

Vascular Emergencies

Aortic dissection occurs when markedly elevated blood pressure contributes to the formation of a tear in the inner layer of the aortic wall, the tunica intima. High-pressure blood then forces its way through the intima into the tunica media (middle layer of the aorta), tearing and separating the layers of the aorta and creating a false lumen. Symptoms of aortic dissection include the acute onset of severe, sharp or “tearing” chest or back pain. Provide routine ALS care to patients with suspected aortic dissection.

Ocular Emergencies

Hypertension can lead to progressive changes to the retinal microvasculature that are categorized under the umbrella of “hypertensive retinopathy.” These changes result from the initial damage caused by hypertension and the adaptive changes that take place in the retinal arteries and arterioles. Patients may complain of headache or decreased vision. Routine ALS care is sufficient in patients with no other signs or symptoms associated with their hypertensive emergency.

Conclusion

“Well,” Mason says, “we are happy to give you a ride to the emergency room to get you checked out, if that’s what you would like.”

“You didn’t answer my question,” Jim says. “Do I need to go?”

“Here’s what’s most likely going to happen if you go to the emergency room,” Jen says. “You will be seen by a doctor, and if you have no complaints, they will very likely just watch you for a few hours, then arrange for you to follow up with another doctor within the week. However, there could be something going on that we can’t identify right now, or your high blood pressure could cause a problem. You could have a heart attack, breathing problems, damage your aorta or have a stroke. It’s possible that this could lead to you getting very sick or even dying.”

“Can I just go and see my own doctor this afternoon?” Jim asks.

“Absolutely,” Mason says, “if you can arrange for yourself to be seen, that’d be great, and the sooner the better. But you have to promise to go see your doctor—this is serious.”

“I’ll call her right now,” Jim says. He calls his family physician on his cell phone while Mason obtains another set of vital signs and Jen fills out the appropriate documentation, including an AMA form. By the time Mason and Jen are finished, Jim has already made an appointment to see his personal physician later that afternoon, and he signs the AMA.

“Now, if anything happens before you get to your doctor’s office,” Jen tells him, “if you experience any chest pain or discomfort, difficulty breathing, dizziness, weakness, syncope, abdominal or back pain, nausea, vomiting or headache, please call us back, and we’ll be happy to come and help you out.”

References

1. Vital Signs: Awareness and Treatment of Uncontrolled Hypertension Among Adults—United States, 2003–2010. MMWR, 2012; 61(35): 703–9.

2. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. Circ, 2010; 121: e46–e215.

3. World Health Organization. Global status report on noncommunicable diseases 2010, www.who.int/nmh/publications/ncd_report2010/en/.

4. Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet, 2005 Jan 15–21; 365(9,455): 217–23.

5. World Health Organization. A global brief on hypertension: Silent killer, global public health crisis, www.who.int/cardiovascular_diseases/publications/global_brief_hypertension/en/.

6. Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med, 2003 Apr; 41(4): 513–29.

7. Grassi D, O’Flaherty M, Pellizzari M, et al. Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles. J Clin Hyperten (Greenwich), 2008 Sep; 10(9): 662–7.

8. Pitts SR, Adams RP. Emergency department hypertension and regression to the mean. Ann Emerg Med, 1998 Feb; 31(2): 214–8.

9. Chobanian AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

10. Aggarwal M, Khan IA. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin, 2006 Feb; 24(1): 135–46.

11. Levy PD. Chapter 84: Hypertension. In: Marx J, Hockberger R, Walls R, Rosen’s Emergency Medicine, 8th ed. Mosby, 2013.

12. Wolf SJ, Lo B, Shih RD, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure. Ann Emerg Med, 2013 Jul; 62(1): 59–68.

13. Gallagher EJ. Hypertensive urgencies: treating the mercury? Ann Emerg Med, 2003 Apr; 41(4): 530–1.

14. Perez MI, Musini VM. Pharmacological interventions for hypertensive emergencies: a Cochrane systematic review. J Hum Hypertens, 2008 Sep; 22(9): 596–607.

15. Decker WW, Godwin SA, Hess EP, et al. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med, 2006; 47: 237–49.

16. Dieterle T, Schuurmans MM, Strobel W, et al. Moderate-to-severe blood pressure elevation at ED entry—hypertension or normotension? Am J Emerg Med, 2005; 23: 474–9.

17. O’Connor RE, Brady W, Brooks SC, et al. Acute Coronary Syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circ, 2010; 122: S787–S817.

Scott R. Snyder, BS, NREMT-P, is a faculty member at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. E-mail scottrsnyder@me.com.

Sean M. Kivlehan, MD, MPH, NREMT-P, is the emergency medicine chief resident at the University of California, San Francisco. E-mail sean.kivlehan@gmail.com.

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is performance improvement coordinator for Airlink/Vitalink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. E-mail kcollopy@colgatealumni.org.