Presentation
This may be
asymptomatic or may present with any of the many symptoms and signs of
end-organ damage:
- Headache
- Fits
- Nausea and vomiting
- Visual disturbance
- Chest pain
- Neurological deficit
- Bleeding due to disseminated intravascular coagulopathy
- Microangiopathic haemolytic anaemia
(Thomas H. 2011)
Causes
- Unilateral renovascular hypertension (Ex: renal artery stenosis)
- Renin-secreting neoplasms
- Trauma to the kidneys
- Renal vasculitis (Ex: scleroderma, polyarteritis andsystemic lupus erythematosus)
- Phaeochromocytoma
- Cocaine abuse
- Drugs such as monoamine-oxidase inhibitors, combined oral contraceptives or the withdrawal of alcohol, alpha stimulants such as clonidine, or beta-blockers.
- Sodium-volume overload and low renin levels (Ex: acute glomerulonephritis, primary aldosteronism)
- Pre-eclampsia/ eclampsia
- Hyperthyroidism
- Hypothyroidism
(Thomas H. 2011)
Investigations
- Full history - including:
- - Past medical history
- - Full systems review
- - Drug history including over-the-counter, herbal remedies and recreational drugs
- Full examination - including:
- - Blood pressure measurements
- - Fundoscopy
- - Cardiovascular examination (look for signs of cardiac failure or pulmonary edema, carotid or renal bruits, left ventricular heave, cardiac murmurs, third or fourth heart sounds)
-
Neurological examination
- Blood tests:
- - FBC ± clotting screen
- - U&Es, creatinine
- - Liver and TFTs
- - Blood sugar measurement
- - ± Cardiac enzymes and fasting blood lipids
- ± Ambulatory blood pressure monitoring
- Urine dip testing for protein and blood
- CXR (cardiac size, cardiac failure, etc.)
- ECG (left ventricular hypertrophy or left atrial enlargement)
- Subsequent investigations may include:
- - CT/MRI scan of the head or kidneys
- - Plasma renin activity
- - Plasma aldosterone level
- - 24-hour urine for vanillylmandelic acid (VMA) and catecholamine levels.
- - Auto-antibody levels (Ex: antinuclear factor)
(Thomas H. 2011)
Stepwise Management
- Initially, try to reduce the mean arterial pressure by approximately 25% over the first 24-48 hours.
- An arterial line is helpful for continuous blood pressure monitoring.
- There may be severe sodium and volume depletion; volume expansion with isotonic sodium chloride solution may be required.
- Drugs
-
Phentolamine is the drug of choice for a
phaeochromocytoma crisis.
(Thomas H. 2011)
REFERENCES
Thomas H. 2011.
Patient.co.uk. [ONLINE] Available at: http://www.patient.co.uk/doctor/hypertensive-emergencies
[Accessed 27th April 15].