Hypertensive Emergency

Hypertension is defined as a blood pressure (BP) ≥130/80 mm Hg. Hypertensive emergency (Table 6) is defined by a BP ≥180/110 mm Hg and signs and symptoms of severely elevated BP. The mechanisms that lead to severely elevated BP appear to be related to a failure of normal autoregulatory function resulting in increased vascular resistance caused by endogenous vasopressors in patients with unrecognized or under-treated hypertension; and/or following the administration of sympathomimetic drugs such as high doses of epinephrine.

Table 6. Hypertensive Emergency.

Prevention:

Identify at-risk patient
- Reduce anxiety
- Ensure profound local anesthesia
  - Use local anesthetic agents containing a vasoconstrictor congruent with the patient’s functional capacity

Signs and symptoms:

Restlessness
Flushed face
Visual disturbances
Dyspnea
- Pulmonary edema/congestive heart failure
A “hammering” pulse
Altered mental state
Chest pain
- Myocardial ischemia, infarction, or aortic dissection
Seizure
- Hypertensive encephalopathy
Cerebral hemorrhage, coma, death

Emergency response:

Place patient in an upright or semi-reclining position
- Notify EMS
  - Administer oxygen
    - 4 to 6 L/min by nasal cannula
  - Monitor vital signs
    - If at any time the patient becomes unresponsive, no normal breathing, and no palpable pulse consider the diagnosis of cardiac arrest
      - Immediate CPR and defibrillation congruent with current recommendations

Nota bene:

In the oral healthcare setting, the BP should not be acutely lowered.
- Tissue perfusion in the brain, heart, and kidneys is tightly regulated within a certain range of mean arterial pressure (MAP), abruptly decreasing the MAP can lead to significant drop in cerebral blood flow and, thus, cerebral ischemia.
Hypertensive urgency (BP ≥180/110 mm Hg, patient is asymptomatic)
- Medical evaluation and risk modification within 24 to 48 hours - same day referral

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