END ORGAN DAMAGE:

·       HT encephalopathy: Presence of CNS dysfunction in a setting of SEVERE HT. Headache,depressed consciousness, vomiting, +/- seizures, +/- focal neurological deficits (if thesepersist, consider a cerebrovascular accident.)

·       Retinopathy: cotton wool exudates, haemorrhages, papilloedema.Stroke/ Intracranial haemorrhage: focal deficits, raised ICT, vomiting, headache, loss of consciousness , +/- neck stiffness.

Do not treat HT in acute ischemic STROKE unless one of the following co-exists:

1.      DBP=>130mm of Hg

2.      Evidence of end organ damage

3.      HT encephalopathy

·       CCF/ unstable angina/MI

·       Renal: worsening of proteinuria, hematuria, renal function.

·       Hematological : Microangiopathic haemolytic anemia, DIC, Thrombocytopenia.

·       HELLP syndrome (severe HT in pregnancy – ecclampsia): Hemolysis, elevated liver enzymes,low platelets.

INVESTIGATIONS:-

As in case of a hypertensive to look for end organ damage.TARGET ORGAN DAMAGE………Brain,Heart, Kidney, Vessels.

SCREEN FOR SECONDARY HT……. Electrolytes (K+), 24hr VMA and potassium in urine,

renal USGDoppler, tests for Cushings (overnight DST)

Look for associated risk factors-Lipids, Blood glucose. Consider the following in case of a pregnant lady:-

·       Platelets (thrombocytopenia),

·       Peripheral blood smear (schistocytes in microangiopathic hemolysis),

·       LFT (elevated enzymes) MANAGEMENT OF HT CRISIS

In the presence of end organ damage, parenteral anti-hypertensives are recommended.

·       For patients with acute ischemic coronary symptoms, NITROGLYCERINE is preferref tonitroprusside. (IV infusion)

·       In pregnancy, alpha-methyl dopa, nifedipine and labetolol appear safe.

·       Captopril is the drug of choice for Scleroderma renal crisis.

·       In aortic dissection, combine nitroglycerine/nitroprusside with a betasdrenergic blocker eg.Propranolol to prevent further dissection.

Do not start these drugs in the casualty without close monitoring before transferring the patient tothe ICU/WARD.

Monitor during patient transport also.

Add on cerebral antioedema measures to bring down the ICT.

Management:- in the absence of acute end organ damage, the anti HT therapy should be throughoral route.

Furosemide (Lasix) can be added on to any of these for enhancement of action. (Dose 40-80 mg PO,repeat 6th hourly).

*CAUTION- Sublingual Nifedipine should not to be used as it can cause a catastrophic fall in bloodpressure.