A 71 year old man comes to the emergency depament because of blurry vision and blood tinged urine. He states that he has a long history of hypeension treated with a beta blocker, an ACE inhibitor and a calcium channel blocker. He repos that he has had 3 days of blurry vision and urine that is “cola” colored. The symptoms began when he ran out of his medications 3 days ago and he has “not had the time” to get the prescriptions refilled. His physical examination is remarkable for a blood pressure of 200/110 mmHg in both arms, and funduscopic examination showing flame hemorrhages and papilledema. Urinalysis shows red blood cells and some dysmorphic red blood cell casts. He has an abdominal bruit. Which of the following is the most appropriate next step in management?
Correct Answer: Give the patient intravenous medication to reduce his BP
Description: This patient has a hypeensive emergency, as evidenced by both the presence of elevated systolic and diastolic blood pressure, as well as evidence of end- organ damage. The blood pressure numbers themselves are a good reason for urgency, but the presence of increased intracranial pressure and renal failure require that this patient be triaged as an emergency. Elevated blood pressure alone, in the absence of symptoms or end organ damage, rarely requires emergency therapy. The therapy for a hypeensive emergency requires IMMEDIATE LOWERING of the blood pressure by approximately 20-30 mm Hg by intravenous administration of medication. The blood pressure should not be reduced to normotensive levels because of the risk of watershed cerebral infarcts with such a dramatic reduction. Ordering an ECG and observing the patient is incorrect. Observation is ceainly warranted, but not without intervention. Giving the patient his usual daily doses of blood pressure medications and observing him would not achieve a rapid enough reduction of the blood pressure, given the presence of end-organ damage on physical examination. Ordering an abdominal CT scan to rule out aoic aneurysm is not an appropriate intervention in the case of an active hypeensive emergency. Ref: Lepe M., Varon J. (2012). Chapter 252. Hypeensive Urgencies. In G.V. Lawry, J. Matloff, D.D. Dressler, D.J. Brotman, J.S. Ginsberg (Eds), Principles and Practice of Hospital Medicine.
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