IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read
Acute evaluation and management of the anterior shoulder dislocation; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to
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JAAPA post-tests. All others may complete and submit the post-test online at no charge at
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KEY POINTS
■ Depending on the type of crisis (emergency or urgency), BP should be reduced gradually or must be reduced immediately to prevent target organ damage. Recognition of the type of manifest hypertensive crisis is paramount to successful management and treatment of the at-risk patient.
■ Hypertensive emergency is defi ned as a severe elevation of BP–usually 220/130 mm Hg or higher–with acute and ongoing target organ damage to the kidneys, heart, vascular system, brain, or eyes. Hypertensive urgency is defined as an elevation of BP–usually 180/110 mm Hg or higher–without target organ damage.
■ The most important task for the ED clinician is to identify whether the patient's condition is a hypertensive emergency or urgency. The goal is to avoid overaggressive treatment of the nonemergent patient while initiating the most appropriate treatment.
Hypertensive crisis is a significant increase in BP, usually to levels higher than 180/110 mm Hg. Hypertensive crises are classified as emergency or urgency. Depending on the type of crisis, BP should be reduced gradually or must be reduced immediately to prevent target organ damage. Recognition of the type of manifest hypertensive crisis is paramount to successful management and treatment of the at-risk patient.
TYPES OF HYPERTENSIVE CRISES
Hypertensive emergency is defined as a severe elevation of BP-usually 220/130 mm Hg or higher-with acute and ongoing target organ damage to the kidneys, heart, vascular system, brain, or eyes. Hypertensive emergency requires the initiation of BP reduction within minutes to hours to prevent further progression of target organ damage. BP should not be lowered to less than 140/90 mm Hg, except in patients with aortic dissection or eclampsia.
Hypertensive urgency is defined as an elevation of BP-usually 180/110 mm Hg or higher-without target organ damage. BP should be lowered gradually over 12 to 24 hours, but not to a normal level (target level, approximately 160/110 mm Hg).
The clinical status of the patient, not the degree of BP elevation, defines an emergency in certain cases. For example, in a patient with acute aortic dissection who presents to the emergency department (ED) with a BP of 160/110 mm Hg, the systolic BP (SBP) must be lowered to less than 120 mm Hg within 20 minutes. The rapid reduction reduces shear stress, thus limiting further dissection of the aorta. On the other hand, a previously nonadherent hypertensive patient who presents to the ED for a reason other than hypertension but has a BP of 220/130 mm Hg and is otherwise asymptomatic does not require immediate BP reduction. The distinction between emergency and urgency should always be made in the ED to prevent overaggressive treatment (Table 1).