HPI

• 48 year old male with PMH HTN presents with blurry vision for 2.5 hours 
• Patient was using the computer tonight, could not see where the icons were on his desktop, could still see light/colors.
• He has no pain in his eyes
• Also reports dyspnea on exertion for 2 days. No headache, no chest pain, no abdominal pain
• He has not had his anti-hypertensives (he reports he is on 5 different medications) for about 1.5 weeks

Physical Exam

T 98.3 BP 290/120, HR 118, RR 18, SpO2 99%

• Patient is awake, alert, conversant, appears well and in no distress
• Neuro: Visual acuity 20/200 OS, OD, OU Normal visual fields Normal pupillary exam Normal extraocular movements Otherwise normal cranial nerve exam Normal strenght in extremities , no pronator drift, normal finger to nose
• Cardiac: tachycardic, normal S1/S1, no murmurs/rubs/gallops
• Pulm: clear to auscultation bilaterally
• Abdomen: soft, nontender, nondistended

Differential Diagnosis 

• Hypertensive emergency with elevated BP and evidence of end organ damage (decreased visual acuity, evidence of pulmonary edema on bedside US) 
• Sympathomimetic toxicity (hypertension, tachycardia), though patient reports no ingestions of medications or drugs
• Thyrotoxicosis 
• CVA given visual changes, however with no focal visual deficits (no visual field cut, decreased acuity is symmetric bilaterally) 

Initial ED Management 

• Arterial line place - IV nicardipine started, with goal SBP 210s (25% reduction in the first hour)
• Bedside lung US performed which demonstrates numerous B lines consistent with evolving pulmonary edema

Labs/Imaging -

• Hb 6.1, PLT 142, WBC 5.92 - Na 147, K 3.7 - Cr 15.03 (last level in chart 3.95 7 years ago) - HS troponin 223 - pro-BNP 26,930
• CT Head with 3 small, distinct areas of intraparenchymal hemorrhage

Further Management 

• Repeat neurologic exam performed and is unchanged
• Neurosurgery consulted, recommend BP goal under SBP 160
• Repeat CTH in 4 hours: unchanged 
• Patient admitted to ICU for IV nicardipine, continuous BP monitoring, and q1 hour neuro checks

Pearls 

• Hypertensive emergency is acute SBP over 180 with evidence of organ dysfunction
• Not every patient with SBP over 180 requires emergency BP control
• In this patient: decreased visual acuity, pulmonary edema, elevated troponin and proBNP, renal failure, and intraparenchymal hemorrhage = hypertensive emergency
• In managing hypertensive emergency, SBP should not be lowered by more than 25% in the first hour to prevent causing hypoperfusion and cerebral ischemia 
• Continuous BP monitoring via arterial line is important to carefully titrate medications
• Nicardepene is an easy to titrate CCB which may be the ideal agent for the treatment of hypertensive emergency
• Indications for emergent dialysis (AEIOU - acidosis, electrolytes, intoxication, overload, uremia): critical metabolic acidosis, refractory or rapidly increasing hyperkalemia, life threatening intoxication with substance that is able to be removed with HD, volume overload, complications of uremia (pericarditis, neuropathy, encephalopathy)