🚨 Hypertensive Emergency

Hypertensive emergency is defined as severe hypertension (typically systolic >180 mmHg or diastolic >120 mmHg) with evidence of acute target organ damage. This is a medical emergency requiring immediate, controlled reduction in blood pressure to prevent irreversible organ damage. UK management focuses on careful titration of intravenous antihypertensives.

Patients may present with headache, altered mental status, visual disturbances, chest pain, dyspnoea, or focal neurological deficits. Signs of target organ damage include papilloedema, acute kidney injury, pulmonary oedema, myocardial ischaemia, or aortic dissection. Differentiate from hypertensive urgency (severe hypertension without acute organ damage).

A: Ensure airway patency. B: Assess breathing rate, effort, and oxygen saturation; administer oxygen if hypoxic. C: Measure blood pressure in both arms, assess for signs of heart failure (JVP, crackles), and obtain a 12-lead ECG. D: Assess conscious level (AVPU/GCS), check for focal neurology, fundoscopy for papilloedema. E: Expose patient to look for signs of trauma or other pathology, check temperature.

Any evidence of new or worsening target organ damage: acute neurological changes (stroke, encephalopathy), acute kidney injury, pulmonary oedema, myocardial infarction, or aortic dissection. Rapidly rising blood pressure or failure to respond to initial treatment are also critical.

Bedside: 12-lead ECG, continuous blood pressure monitoring, pulse oximetry, blood glucose. Bloods: FBC, U&Es (renal function), LFTs, cardiac enzymes (troponin), arterial blood gas. Urine: Urinalysis for proteinuria/haematuria. Imaging: CT head (if neurological symptoms), chest X-ray (pulmonary oedema), echocardiogram (aortic dissection/heart failure).

Admit to a high-acuity area (HDU/ICU). Administer intravenous antihypertensives to gradually reduce mean arterial pressure by 10-25% in the first hour, then more slowly over the next 24-48 hours. Avoid rapid or excessive blood pressure reduction, which can cause ischaemia. Specific agents depend on the type of organ damage (e.g., labetalol for aortic dissection, GTN for pulmonary oedema).

Immediate senior medical review (Registrar/Consultant) is required for all cases of hypertensive emergency. Critical care (HDU/ICU) admission is often necessary for close monitoring and intravenous drug titration. Specialist input (neurology, cardiology, renal) may be required depending on the affected organ system.

The goal is controlled BP reduction, not normalisation, to prevent hypoperfusion. Malignant hypertension is a severe form with papilloedema and/or renal failure. Always rule out secondary causes of hypertension, especially in younger patients. Differentiate from hypertensive urgency, which can be managed with oral agents over hours/days.