Dealing with hypertensive
emergency and urgency
Your patient’s blood pressure is skyrocketing. Here’s how to defuse the crisis.
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Peter Thurgood, 74, arrives at your hospital’s emergency
department (ED) feeling miserable, complaining of a se-
vere occipital headache, nausea and vomiting, and blurred
vision; his skin also appears flushed. When checking his vi-
tal signs, you discover that his blood pressure (BP) is
220/140 mm Hg.
Mr. Thurgood tells you that to treat his hypertension,
for the last 3 years or so, he’s been taking Prinzide, a com-
bination of lisinopril, an angiotensin-converting enzyme
(ACE) inhibitor and hydrochlorothiazide, a thiazide-type
diuretic. But he hasn’t taken the drug for 3 weeks because
his prescription ran out and he couldn’t afford to refill it.
Based on Mr. Thurgood’s history and your assessment
findings, you suspect that he’s experiencing a hypertensive
crisis. This condition can occur in patients who have
poorly controlled hypertension or, as in Mr. Thurgood’s
case, have abruptly stopped taking their antihypertensive
medications. For more information on the causes of hy-
pertensive crises, see Behind the high rise.
Now let’s look at how to safely lower Mr. Thurgood’s
soaring BP as quickly as possible.
Take action, stat!
The two types of hypertensive crises—hypertensive emer-
gency and hypertensive urgency—share a common sign: se-
verely elevated BP, usually defined as a diastolic pressure
that exceeds 120 mm Hg. In a hypertensive emergency, the
elevated BP causes target organ damage (brain, eyes, blood
vessels, heart, and kidneys). Although the BP is also ele-
vated in a hypertensive urgency, there’s little or no evi-
dence of target organ damage.
ED Insider
Behind the high rise
Hypertensive crises may arise as the result of one or
more of the following:
• acute glomerulonephritis
• autonomic dysreflexia in the presence of spinal cord
injury
• chronic parenchymal renal disease
• combining a monoamine oxidase inhibitor and
tyramine-containing foods (such as soy sauce, sauer-
kraut, aged cheese, pepperoni, salami, liverwurst), tri-
cyclic antidepressants, or other sympathomimetics
• eclampsia, preeclampsia
• head injury
• illicit use of sympathomimetic drugs such as cocaine,
amphetamines, PCP, and LSD
• pheochromocytoma
• renin-secreting or aldosterone-secreting tumor
• renovascular hypertension
• scleroderma and other collagen vascular diseases
• too-rapid withdrawal from antihypertensive medica-
tions
• vasculitis.
In a hypertensive emergency, the patient’s BP must be
lowered at once to halt the acute, progressive damage to
the target organs. Conditions associated with hypertensive
emergencies include hypertensive encephalopathy, acute
left ventricular failure with pulmonary edema, acute myo-
cardial infarction, dissecting aortic aneurysm, intracerebral
hemorrhage, and eclampsia.
18 Fall 2006
 This type of crisis is acute, life-threatening, and re-
quires immediate treatment in an intensive-care setting.
The patient typically has chest pain, dyspnea, neurologic
deficits, an occipital headache, visual disturbances, and
vomiting.
When you take the patient’s history, ask about a previ-
ous diagnosis of hypertension, how long he’s had it, how
well it’s controlled, and what drugs he’s taking for it. Also
ask about established target organ damage, such as kidney
disease, heart failure, and stroke. Be sure to perform med-
ication reconciliation.
If hypertensive emergency is suspected, lab testing
should include a complete blood cell count, cardiac mark-
ers, blood urea nitrogen, creatinine, urinalysis, and a urine
toxicology screen.
Other diagnostic procedures to be considered include
computed tomography scans of the chest, abdomen (to
rule out aortic dissection), and brain (to rule out hemor-
rhagic stroke); a chest X-ray; transthoracic echocardiogram
or transesophageal echocardiogram; and electrocardio-
gram.
At the front of the line
A patient diagnosed with a hypertensive emergency needs
fast-acting therapies to prevent or limit target organ dam-
age and improve his chance of survival. A first-line medical
therapy in this situation is labetalol, an adrenergic receptor
blocker with both selective alpha1-adrenergic and nonse-
lective beta-adrenergic receptor blocking actions. This
drug is available in intravenous (I.V.) and oral forms. In a
hypertensive emergency, use the I.V. route.
Labetalol decreases BP by causing vasodilation without
compromising cerebral blood flow. The drug is contraindi-
cated in patients with asthma, acute heart failure, cardio-
genic shock, severe bradycardia, and greater than
first-degree heart block without a pacemaker.
Vasodilators such as nitroprusside and nitroglycerin
are also used to treat a hypertensive emergency.
The goal of therapy for a hypertensive emergency is to
lower the mean arterial pressure by no more than 25%
within minutes to 1 hour and then stabilize BP at 160/100-
110 mm Hg within the next 2 to 6 hours. This slow and
steady approach is important: Lowering the BP too
abruptly can lead to inadequate cerebral, renal, or coro-
nary blood flow.
Hypertensive urgency:
A wider window of opportunity
In a hypertensive urgency, the window of opportunity for
treatment is open a bit wider because no target organ dam-
age has occurred. The BP can be lowered gradually over 24
Fall 2006
to 48 hours, and it can even be done on a closely moni-
tored outpatient basis.
Hypertensive urgency is usually managed with a com-
bination of oral fast-acting agents such as loop diuretics
(bumetanide, furosemide), beta-blockers (propranolol,
metoprolol, nadolol), ACE inhibitors (benazepril, capto-
pril, enalapril), calcium channel blockers (amlodipine, ver-
apamil), or a centrally acting alpha agonist such as
clonidine.
If you’re treating a patient with a hypertensive urgency
in the ED, monitor him for a couple of hours after admin-
istering one of these drugs to make sure that he’s respond-
ing to treatment and that he isn’t experiencing any serious
adverse reactions. Try to determine the cause of the hyper-
tensive urgency—for example, has he stopped taking his
antihypertensive medications? Advise him to schedule ap-
propriate follow-up care after discharge, usually within 24
to 48 hours.
Crisis over; now what?
Mr. Thurgood has a hypertensive emergency, so getting his
BP down safely and quickly is the immediate goal. Estab-
lish I.V. access, administer I.V. labetalol as ordered, and
transfer him to the cardiac care unit for further monitor-
ing.
After 24 hours, his BP is down to 150/80 mm Hg. His
oral antihypertensive drug has been restarted, and he’s also
on the beta-blocker atenolol. Instead of prescribing
Prinzide for discharge, though, the health care provider
writes a prescription for the individual drugs (lisinopril
and hydrochlorothiazide). When money is an issue, this
can be a good strategy: Individual drugs are generally less
expensive than combination products.
Mr. Thurgood now knows that it’s dangerous to stop
any of his antihypertensives. Before discharge, he’s given a
referral to an advocacy group for older adults that can help
with his prescription coverage and arrange home health
care visits a couple of times a week.
Thanks to you and the rest of the health care team, Mr.
Thurgood is discharged 2 days after arriving in the ED. His
BP is now 138/88 mm Hg and he’s feeling better—and he’s
going home to a safer environment with the support he
needs. ■
SELECTED REFERENCES
Bisognano JD, Orsini AN. Malignant hypertension.
http://www.emedicine.com/med/topic1107.htm. Accessed May 1, 2006.
The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure, Publication
No. 04-5230. Bethesda, Md., National Institutes of Health, August 2004.
Adapted and updated from When blood pressure goes up, up, and away!
Nursing made Incredibly Easy! July/August 2005.
19 ED Insider