Medical Malpractice — Hypertensive Crisis

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More than 50 million Americans suffer from hypertension (high blood pressure), and approximately 1% or 500,000, will suffer a hypertensive crisis that can result in severe damage to the brain, heart, kidneys and other organs.

Hypertensive crisis is a state in which blood pressure becomes so high that it requires prompt medical attention to prevent the possibility of stroke, organ damage and even death. The organs most in danger of damage from a hypertensive crisis include the brain, heart, lungs and kidneys.

Although blood pressure readings are not the only marker of hypertensive crisis, typically a diastolic blood pressure (the lower number in a blood pressure reading which measures the pressure of blood in the arteries between heartbeats) in a hypertensive crisis is greater than 120. A normal diastolic reading is considered to be 79 and lower.

The good news is that a number of rapidly-acting medications are available to quickly and safely lower dangerously elevated blood pressure levels. The bad news is that not all emergency room doctors and nurses are properly trained to recognize the signs of hypertensive crisis, to act quickly enough to prevent serious damage, and are familiar enough with medication options to know which ones to use when – and how to reduce blood pressure quickly enough to save lives and organs, and slowly enough not to cause additional damage from too rapid a change.

Types of Hypertension Crises

A hypertensive crisis can be characterized as either a hypertensive urgency or a hypertensive emergency. Both require medical attention.

A hypertensive urgency is when blood pressure spikes, but there is no damage to the body’s organs, and the blood pressure can be brought down safely within a few hours outside the hospital setting using oral agents rather then IV medication. The red flag here is that a hypertensive urgency requires vigilant follow-up care and close management of the patient. Hypertensive urgency includes the upper levels of stage 3 hypertension, papilledema, severe headache, anxiety, shortness of breath, and/or pedal edema, but no impending target organ damage or cardiovascular danger. Most hypertensive crises seen in a hospital emergency room are of this variety. Unlike a hypertensive emergency which usually has sudden onset, a hypertensive urgency may develop over days or weeks. Examples of common causes include hypertension associated with coronary artery disease, preoperative or postoperative hypertension, and uncontrolled hypertension in the patient with increased intracranial pressure.

A hypertensive emergency on the other hand, is characterized by severely elevated pressure coupled with progressive or impending organ damage. This form of hypertensive crisis usually involves immediate admission to an intensive care unit (ICU), prompt administration (by injection) of antihypertensive drugs to bring the blood pressure down in a slow, steady and safe manner; and vigilant and continuous monitoring of the patient’s blood pressure.

Emergency Hypertensive Crisis

An emergency hypertensive crisis often presents with these signs accompanying the elevated blood pressure:

  1. Severe headache
  2. Severe anxiety
  3. Shortness of breath (dyspnea)
  4. Headache
  5. Seizure
  6. Chest pain (angina)
  7. Swelling or edema (fluid buildup in the tissues)
  8. Swollen or bleeding eyes

Examples include hypertension-induced intracerebral and subarachnoid hemorrhage, encephalopathy, or cerebral infarction. A hypertensive crisis can be triggered by surgery, excess dietary salt intake, or a worsening of existing hypertension that goes undetected. A hypertensive crisis can also be triggered by neurological conditions, alcohol withdrawal, the use of illegal drugs like cocaine, or taking over-the-counter preparations that contain pseudoephedrine.

If not treated quickly enough, the following conditions may also be present or develop in short order, indicating target organ damage:

  1. Fluid in the lungs (pulmonary edema)
  2. Brain swelling (edema) or bleeding (hemorrhage)
  3. Separation of the walls of the aorta (aortic dissection)
  4. Heart attack- acute myocardial infarction
  5. Eclampsia in pregnant women
  6. Changes in mental status such as confusion or coma (encephalopathy)
  7. Bleeding into the brain (stroke) – cerebral infarction
  8. Heart failure
  9. Aneurysm (Bulging blood vessel)
  10. Hypertensive encephalopathy
  11. Intracranial hemorrhage
  12. Acute left ventricular failure with pulmonary edema
  13. Dissecting aneurysm
  14. Encephalopathy
  15. Intracerebral or subarachnoid hemorrhage
  16. Acute congestive heart failure with pulmonary edema
  17. Acute myocardial infarction or unstable angina
  18. Aortic dissection

When organ damage occurs as a result of severely elevated high blood pressure, this is considered a hypertensive emergency. When this occurs, blood pressure must be reduced immediately to prevent further organ damage. This is almost always done in an intensive care unit of a hospital.

Time is of the Essence

Proper and prompt diagnosis of a hypertensive crisis and immediate and appropriate treatment can be the difference between life and death as well as the difference between recovery and permanent disability.

The availability of drugs that can control blood pressure in time to avert stroke, death and other damage, make it incumbent upon medical professionals to recognize the signs and symptoms of hypertensive crisis and begin immediate treatment. Evidence from a recent study suggests that more than 25% of medical visits to emergency rooms are motivated by hypertensive crisis. Thus, it is incumbent upon doctors, and especially emergency room doctors, nurses and other emergency room personnel to recognize blood pressure crises and to respond quickly and appropriately.


Treatment of a hypertensive emergency almost always involves parenteral (by injection) administration of anti-hypertensive medication in an intensive care unit. The first goal is to bring down the blood pressure to prevent further organ damage. Today’s blood pressure medications are so effective and so potent, that sometimes the challenge is in bringing the blood pressure down slowly enough so as not to create any additional damage. There is a number of drug choices available with both parenteral (by injection or IV) or oral administration, and each has advantages and disadvantages. Then, whatever organ damage that has occurred is treated with therapies specific to the organ that is damaged.

An Added Danger: Too Low, Too Soon – Rapidly reduction has its dangers.

The initial goal for reducing alarmingly high blood pressure (BP) is to achieve a progressive, controlled reduction in pressure to minimize the risk of hypoperfusion in cerebral and coronary veins and arteries. Organ circulation may be put at risk with sudden reductions in blood pressure. Excessively rapid reductions have been associated with acute deterioration in renal function, ischemic cardiac or cerebral events, and occasional retinal arterial occlusion and acute blindness.

Whereas the goal used to be to reduce blood pressure as fast as possible with strong vasodilating drugs, a too rapid reduction in blood pressure – especially in those with chronic hypertension – has been shown to lead to its own form of organ damage (organ hypoperfusion) with often irreversible consequences. Thus, careful choice of which blood pressure lowering drug to use, vigilant monitoring of blood pressure patients during the administration of drugs, and careful following of reduction protocols (how much percent over a certain period of time) is critical so that blood pressure is not lowered too aggressively. Reduction percentages and time frames vary widely depending on the condition and conditions of the patient and must be strictly followed to ensure safe lowering of the blood pressure.

Hypertensive Crisis Protocols

In order to properly, promptly and correctly diagnose a hypertensive crisis and start appropriate and swift treatment, the emergency room staff should follow these general protocols:

  1. Common protocol is that BP reduction should be started immediately in order to avoid or minimize target organ damage. Waiting for a battery of tests and test results might be too long and too late.
  2. Blood pressure monitoring should begin immediately
  3. Medication should be chosen carefully and blood pressure lowering must be down slowly with vigilant monitoring to prevent hypopofusion.
  4. A thorough physical exam, including eye exam to evaluate swelling and bleeding, should be conducted. An appropriate physical exam should include BP cuffs in both upper extremities and in a lower extremity if peripheral pulses are markedly reduced. Brachial, femoral, and carotid pulses should be assessed. A careful cardiovascular examination as well as a thorough neurologic examination, including mental status, should be conducted. If a secondary cause of hypertension is suspected, appropriate blood and urine samples should be obtained before aggressive therapy is initiated.
  5. A thorough medical history must be taken, including all prescription, non-prescription and recreational drugs taken, as well as herbal and dietary remedies; obviously particular attention should be paid to hypertensive history and treatments. Details about neurological, cardiovascular and renal disease are also important.
  6. Check for common signs of hypertensive crisis include headache, seizures, chest pain, dyspnea, and edema as well as those listed above.
  7. A careful funduscopic examination should be performed to detect the presence of hemorrhages, exudates, and/or papilledema.
  8. Laboratory tests should include, when appropriate, a urinalysis, a chemistry panel, and an electrocardiogram. When the clinical examination suggests cerebrovascular ischemia or hemorrhage, or if the patient is comatose, a CT scan of the head should be immediately obtained.

Brain Damage/Stroke

The brain is particularly vulnerable to the effects of severe hypertension. Extremely high blood pressure damages blood vessels, which then leak fluid or blood into the brain, leading to stroke and, often, disability. Understanding hypertensive crisis and its impact on the brain is a crucial responsibility of emergency doctors, nurses and other personnel.

Hypertensive Crisis Malpractice

The issues in hypertensive crisis malpractice include:

  1. Failing to recognize the symptoms of a hypertensive crisis
  2. Misdiagnosis
  3. Late diagnosis
  4. Failure to start medication and treatment promptly enough to prevent target organ damage
  5. Choosing the wrong medication
  6. Failure to properly monitor blood pressure and other symptoms during a hypertensive crisis
  7. Bringing blood pressure down too quickly, causing hypopofusion

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