All Emergencies - Basic life support principles:

1. Maintain an airway
2. Assess breathing
3. Monitor circulation

Most Common Causes:

1. Poorly controled pre-existing hypertension
2. Inadequate analgesia or sedation
3. Abnormal blood gases
4. Medications - overuse of sympathomimetics, especially epinephrine

Management:

Symptomatic:

1. If symptomatic and diastolic BP > 100, administer nitroglycerine - 1 tab q5 min, up to 3 times.
2. If still symptomatic, activate EMS
3. Malamed states acute hypertension is extremely uncommon. Nitroglycerin or nifedipine (Procardia) can be used to lower BP

Asymptomatic:

1. Deepen the sedation and analgesia in parallel with changing stimuli
2. Prevent hypercapnia (elevated CO2) & hypoxemia
3. Rule out less common causes

If IV can be started

• Establish IV infusion
• Titrate nitroprusside (Nipride) @ 5 mg/kg/min infusion rate until BP lowered to desired point
• If myocardial infarction or congestive heart failure is present:
  • IV nitroglycerin or nitroprusside (50 microgram bolus, followed by 10-20 microgram/minute
  • IV Diazoxide (Hyperstat) - administer 1-3 mg/ky, up to 150 mg. May repeat q5-10 min. up to 600 mg.
  • When anxiety is a major component of the hypertension - midazolam or diazepam can be titrated

Source: Sedation, A Guide to Patient Management by Stanley F. Malamed