Hypertensive Crisis

A hypertensive crisis is a sudden and severe increase in blood pressure, where systolic pressure is above 180 and/or diastolic pressure is above 120 mmHg. There are two types of hypertensive crisis: 

• Hypertensive urgency – an otherwise stable patient has an elevation in blood pressure without signs of organ damage. This usually occurs in patients who have not been following sodium restrictions adequately and/or not taking their antihypertensive medications as prescribed. Hypertensive urgency is much more common than a true hypertensive emergency. 
• Hypertensive emergency – Elevation of systolic and diastolic blood pressure with signs of end-organ damage.

Nursing response to elevated blood pressure

The first thing to do when you obtain a markedly elevated blood pressure reading is to reassess the patient. Ensure the cuff is the appropriate size, that it’s applied correctly, and that the patient is still and quiet while the reading is occurring. The patient should be seated (or in Semi-Fowler’s position if in bed, if not contraindicated) and the legs should be uncrossed. Check that the arm is supported at the level of the heart, and have the patient sit quietly for five minutes prior to measurement.

Evaluate if the patient has end-organ damage

Acute and severe elevations in blood pressure can affect the body’s organs in several ways, so patients experiencing hypertensive emergency can exhibit a wide range of signs and symptoms:

• Neuro: Changes in LOC, confusion, neurological deficits, blurred vision, nausea/vomiting, seizures, and even stroke
• Ocular: Retinopathy
• Pulmonary: Shortness of breath due to pulmonary edema
• Cardiac: Myocardial ischemia, arrhythmias, acute heart failure
• Vascular: Aortic dissection (causes severe chest and/or back pain)
• Renal: Acute renal failure
• Pregnancy: Eclampsia (occurs when preeclampsia progresses to the point of inducing seizure activity)

How is hypertensive crisis treated?

One key thing to know about treating hypertensive crisis is that the blood pressure should not be dropped too quickly. Doing so can cause ischemic damage in vascular beds that have become accustomed to the higher pressure. In most cases of hypertensive emergency, the mean arterial pressure (MAP) is reduced by 10 to 20 percent in the first hour, and then an additional 5 to 15 percent over the next 23 hours. 

So what might this look like?

Your patient has a severe headache and blurred vision with a blood pressure of 187/112 and a MAP of 137. In the first hour, MAP should be reduced no lower than 109. Over the next 23 hours, the MAP will be reduced to a range of 93 to 103.

Exceptions to slow blood pressure reduction

However, it is important to note there are exceptions. Patients experiencing ischemic stroke who are candidates for reperfusion therapy do not usually have hypertension treated unless the blood pressure is ≥ 185/110. If the patient is not a candidate for reperfusion therapy, blood pressure is allowed to remain even higher (up to ≥ 220/120) to get as much blood flow to the brain as possible.

If the patient is experiencing an aortic dissection, this is a very serious medical emergency. These patients will have blood pressure lowered rapidly to reduce further aortic injury. Patients with intracerebral hemorrhage will also have more aggressive and rapid blood pressure control.

Medications

Treatment for the patient will be tailored to each individual situation and can vary based on specific complications. Common medications used include: 

• Vasodilators – nitroglycerine, nitroprusside, and hydralazine. These medications lower blood pressure by causing systemic vasodilation. Note that hydralazine causes reflex tachycardia which puts more work on the heart. For this reason, it is generally avoided in patients with acute heart failure and acute coronary syndrome.
• Calcium channel blockers – nicardipine. This type of calcium channel blocker mainly exerts its action on blood vessels, causing them to dilate (which lowers blood pressure).
• Beta blockers – metoprolol and esmolol. These medications decrease blood pressure by slowing the heart rate and decreasing contractile force.

Once the blood pressure reaches and maintains safe levels with IV medication, the patient is transitioned to oral medications.

What can cause a hypertensive crisis?

Hypertensive crisis can occur for many reasons beyond noncompliance with blood pressure medications. Others include:

• Renal failure: The patient may become hypertensive due to a variety of factors including fluid volume overload, increased vascular resistance, and activation of the RAAS pathway.
• Stimulants: Both illicit and legal drugs can precipitate hypertensive crisis. These include methamphetamine, cocaine, glucocorticoids, NSAIDs, and nasal decongestants.
• Endocrine dysfunction: Both Cushing syndrome and thyrotoxicosis can lead to dangerously high blood pressure.
• Pheochromocytoma: In this condition, a neuroendocrine tumor located on the adrenal glands causes the body to release too much norepinephrine and epinephrine.
• Heart failure: A patient with heart failure may become severely hypervolemic, which can increase blood pressure significantly.
• Withdrawal: Patients going through alcohol or benzodiazepine withdrawal can experience dangerously high blood pressures. In addition, a patient who has abruptly and recently stopped taking clonidine (an antihypertensive) can experience hypertensive crisis.
• Excessive sodium intake: A patient with underlying hypertension can go into hypertensive crisis from excessive sodium intake.

So there, you have it! Your quick overview on hypertensive crisis. I hope this lesson has helped you understand this condition with more clarity. If you’d like to dive into the medications mentioned in more detail, then I invite you to check out Fast Pharmacology. In this audio-based program, I teach pharmacology concepts in FIVE MINUTES OR LESS! Get all the juicy details here!

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Last Updated on December 10, 2024 by Maureen Osuna, MSN, RN