Hypertensive Crises
Hypertensive crises are a common medical emergency. End-organ damage of the brain, aorta, heart, and kidneys in the setting of uncontrolled hypertension define the crisis. The degree of organ damage does not correlate directly with the degree of blood pre
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Mark Schmidhofer
Case Presentation A 67-year-old man was driven to the emergency room by his wife when he began acting strangely and massaging his sternum. He previously had been reasonably healthy, with past medical history significant for hypertension and hyperlipidemia. His prescribed medications included hydrochlorothiazide 12.5 mg daily, enalapril 5 mg twice daily, amlodipine 10 mg daily, clonidine 0.3 mg twice daily, combination simvastatin and ezetimibe, 81 mg of aspirin, and prn ibuprofen. His wife reported that his prescriptions all ran out 2 days prior to admission. Physical examination revealed an overweight, restless man who was oriented to name and location but not the date. When asked if he was having chest discomfort, he looked up quizzically and rubbed his forehead. He was afebrile, respiratory rate was 28 breaths per minute, heart rate was 115 beats per minute, and blood pressure was 235/130. His lungs were clear to auscultation. Cardiac exam revealed a regular S1 and S2, an S3 and prominent S4, but no murmurs. His abdomen was soft and non-tender. He had no edema. Neurologic exam revealed no focal deficits.
M. Schmidhofer Department of Medicine, University of Pittsburgh School of Medicine, Heart and Vascular Institute, UPMC Health System, Pittsburgh, PA, USA e-mail: [email protected]
Bedside ultrasound showed his optic nerve sheath to be 5.3 mm in diameter, B lines in both lung fields, and hyperdynamic left ventricular function without regional wall motion abnormalities or valvular dysfunction. His electrocardiogram (ECG) is shown in Fig. 15.1. Basic metabolic profile demonstrated a plasma glucose of 139, creatinine of 1.4 mg/dL and a BUN of 30 mg/dL. His CBC was within normal limits. Urinalysis showed trace proteinuria, modest red blood cells, and no casts. His cardiac troponin was normal. Question What is the diagnosis? Answer Hypertensive crisis. The patient presented with significant hypertension and end-organ dysfunction including hypertensive encephalopathy, acute kidney injury, and myocardial ischemia by ECG. He was treated with IV labetalol and intravenous nitroglycerin. Within the first hour, his blood pressure was reduced to 210/115. Labetalol and nitroglycerin were both uptitrated and furosemide was administered. Head CT showed no acute abnormalities. Upon obtaining further history, his wife mentioned that he was a recreational drug user, and the previous day had used cocaine. Urine drug screen was positive. Benzodiazepines were started. An arterial line was placed for invasive blood pressure monitoring. A repeat cardiac troponin was elevated at 4.3. Over the course of the next 24 h, his blood pressure came down to 175/100 and heart rate
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_15
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Fig. 15.1 Admission EKG
to 90. His mentation improved, he said he was having no chest discomfort, his lungs were clear to auscultation, and the S3 was no longer audible. The foll
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