Special Operations Forces Medical Handbook

4-5

Cardiac: Hypertensive Emergency

CAPT Kurt Strosahl, MC, USN

Introduction: Most hypertension does not require intervention in the eld but should have further evaluation
and treatment upon completion of the mission. A hypertensive emergency is dened as acute hypertension
with damage resulting to other organs. The diastolic BP is usually over 110 mg Hg. Marked hypertension
may accompany head trauma.

Subjective: Symptoms
Headache; blurred vision; neurologic decits; decreased urination; shortness of breath while walking or sitting
that worsens when lying down; fatigue; nausea; lack of energy; confusion and chest pain.

Objective: Signs
Using Basic Tools: BP >220/120; bounding pulses; swelling of the legs; cyanosis; tachypnea, tachycardia
or bradycardia; blurring of the optic disc or red splotches of hemorrhage on the retina on fundoscopic
examination; lungs may be clear or have rales of CHF or pulmonary edema; forceful heartbeat on chest wall;
loud bruit just above the umbilicus in renal artery stenosis; decreased urinary output from renal dysfunction
(as either a cause or an effect); neurologic defects. Organ damage of note includes effects on heart, brain,
eyes and kidneys.
Using Advanced Tools: Lab: Protein and casts on urinalysis (renal failure); HCT (anemia suggests hemor-
rhage)

Assessment:

Differential Diagnosis
Acute renal failure - casts seen in the urine sediment
Stroke - focal neurologic decit or depressed consciousness
Aortic dissection - >10 mm difference in systolic BP between the arms
Closed head trauma with elevated intracranial pressure - history of trauma, wound on the head, pupils different
in size.

Plan:

Treatment
Treat acute hypertension if evidence of organ damage, or if BP reaches 220/120. Below 200/110, there is no
acute benet to treatment in the absence of end-organ damage.
Primary: Sedation: diazepam 5 mg; Diuresis: furosemide 20 mg IV (or po) and double every 30 minutes
until diuresis occurs.
Alternative: Use antihypertensives to lower the diastolic pressure to 100-110, not to under 90, in the rst 24
hours: lisinopril 10 mg po or enalapril 5 mg po qid; clonidine 0.1 mg po q 1hour up to 6 doses.
Primitive: Sitting or elevating the head is essential if head trauma is suspected. Phlebotomy of 500 cc
(withdraw one unit by gravity into an empty IV uid bag) if pulmonary edema is present and diuresis not
possible.

Patient Education
General: Hypertension is a common, chronic disease that CAN be controlled with diet, exercise and
medications to minimize the risk of stroke, kidney failure or heart failure. There is no need to acutely treat
hypertension unless organ damage is evident.
Activity: Rest will lower the BP. Strenuous physical exertion will raise the pressure and should be minimized
until BP stable.
Diet: Avoid salt and salty foods.
Medications: Antihypertensive medications are often sedating and can cause orthostatic hypotension.
Prevention and Hygiene: Exercise, weight control, and salt avoidance.
No Improvement/Deterioration: Return for reevaluation.