Arterial hypertension (AH) is a continuously progressive disease. It is characterized by a constant increase in blood pressure (BP), which, with a sufficiently responsible attitude of the patient to the prescribed treatment, is successfully corrected by taking medications. The episodes of a significant increase in blood pressure, regardless of the intensity of drug therapy, are called crises. Emergency care for hypertensive crisis (GC) should be provided in a timely manner and in full to prevent serious complications.
Express diagnosis of hypertensive crisis
To determine the hypertensive crisis, it is enough to measure blood pressure. In the generally accepted interpretation, such a concept as HA includes a significant increase in blood pressure with the development of specific symptoms. There are no strict boundaries above which an increase in blood pressure is called a crisis. The main criterion is precisely the relationship between the increase in blood pressure and the onset of symptoms. Typical symptoms of uncomplicated HA that require correction:
- pressing headaches;
- darkening in the eyes, redness of the face;
- flickering of "flies" before the eyes;
- the appearance of nausea, sometimes vomiting, pressing sensations in the neck;
- noise in ears;
- sometimes a sensation of pulsation in the temporal region of the head.
The appearance of these symptoms along with an increase in blood pressure, as well as their aggravation as pressure rises, indicates the development of a crisis and the need for emergency care. Often, patients with high blood pressure are not accompanied by any symptoms, especially with resistant hypertension. Conversely, some patients, even with a slight increase in blood pressure, feel discomfort. Despite this, both the first and second cases are an example of a hypertensive crisis and require medical correction.
Types of complications of HA
Standards of care for hypertensive crisis are a set of actions, research methods and prescriptions of drugs that should lead to the normalization of blood pressure and the elimination of symptoms. They depend on the nature of the crisis, the presence of complications and the stage at which assistance is provided. Here, the most important element is the presence of complications, on which further actions depend. The list of complications is as follows:
- acute left ventricular failure (VLF);
- acute hypertensive encephalopathy (OGE);
- acute cerebrovascular accident (stroke);
- myocardial infarction or acute coronary syndrome (MI or ACS);
- stratified aortic aneurysm.
Each of these conditions is accompanied by specific symptoms and requires special help. To recognize them, you should remember some symptoms.
Symptoms of OLZHN, ONMK, OGE
With ARF, against the background of high blood pressure, there is a significant increase in dyspnea, the development of a dry, and after a wet cough, a strong feeling of weakness. As the swelling increases, bubbling breathing and a feeling of acute shortage of air, a constant feeling of dissatisfaction with the breath appear. In the supine position, the patient is worse, while lowering the legs and sitting down, relief of well-being is achieved. Outwardly, cyanosis of the lips is easily noticeable, sometimes a grayish pale skin color of the legs with a bluish tinge on the fingers, legs and feet.
The manifestations of OGE and ONMK at the initial stage are almost identical, which causes a number of diagnostic difficulties. With stroke, depending on the affected area, the following symptoms are observed: speech impairment up to aphasia, paralysis and paresis of the extremities, loss of consciousness, impaired coordination, lowering of the corner of the mouth and the development of facial asymmetry, less often impaired swallowing.
Myocardial infarction
More than 80% of myocardial infarction occurs against the background of increased blood pressure. Therefore, in a crisis, the likelihood of its development increases. Symptoms of this are the appearance of severe pressing or burning pains in the projection of the heart, extending to the left arm, under the left shoulder blade or in the interscapular region, sometimes in the region of the lower jaw. If such sensations are completely removed by taking nitroglycerin, we are talking about angina pectoris against a background of high blood pressure. But if the pain does not stop with nitrates and lasts more than 30 minutes, the development of acute coronary syndrome or myocardial infarction cannot be ruled out.
Exfoliating Aortic Aneurysm
With stratified aortic aneurysm, a specific symptom is pain, the intensity of which depends on the pressure values. The higher it is, the more pronounced are the pain in the chest. They are of a pressing or burning nature, resemble those of a heart attack, but of much greater strength. A specific symptom is a lack of response to nitrate intake. Also, if blood pressure decreases, pain is also significantly reduced.
It is important to understand that stratified aneurysm is a formidable complication of a hypertensive crisis. But it will never occur if there is no aortic aneurysm. More importantly, if at the time of increasing blood pressure any of these symptoms occurs, the standard algorithm of action for a patient with a hypertensive crisis changes. Then, in a short time, you need to contact an ambulance about the complications of HA.
Crisis Aid Specifics
Since the number of hypertensive crises is huge, and most of them do not require complex diagnostic and therapeutic measures, first aid is widely practiced. With a hypertensive crisis, the patient stops it himself. But if there are signs of complications or if the self-treatment is ineffective, you should contact an ambulance or the emergency room of the hospital. This means that for any complications of the crisis of hypertension, independent treatment should be excluded and seek specialized help. But if there are no complications, and they do not appear in the process of self-treatment, then the patient himself can successfully stop the increase in blood pressure.
Algorithm of patient actions in episodic HA
When symptoms of a hypertensive crisis are identified, treatment does not begin immediately. Initially, you should make sure that the value of blood pressure is high or significantly exceeds the normal figures, at which the state of health was previously comfortable. If the blood pressure is high, then you need to try to calm down, take a comfortable position (preferably lie down) and, after eliminating the above complications, take medications recommended by your doctor.
What to do with a hypertensive crisis if it occurs for the first time or there are no medical recommendations? It is necessary to take the drug "Captopril" or "Nifedipine", and if there are no such drugs, then contact the SMP. With a simple hypertensive crisis, “Captopril” is a universal medicine that is contraindicated only in chronic renal failure, the development of allergies, during pregnancy and lactation. It is taken sublingually: the tablet or part of it is absorbed under the tongue. Its action begins 7-10 minutes after administration, and the peak occurs after 30 minutes.
With an increase in blood pressure by 20 mmHg above normal, 12.5 mg should be taken, above 40 mmHg - 25 mg. With insufficient effectiveness of the drug, you need to repeat the dose after 15-30 minutes. Instead of Captopril, Nifedipine 10 mg is excellent. With an increase of no more than 20 mmHg, 5 mg can be taken, with an increase in blood pressure of 40 mmHg or more - 10 mg. The tablet is absorbed under the tongue and is faster than Captopril. Reception may be accompanied by unpleasant but safe side effects: redness of the face and a feeling of heat in the cheeks and neck, redness of the sclera of the eyes.
These drugs are the easiest to provide emergency care for hypertensive crisis. They can be taken together, but this tactic with infrequent increases in blood pressure is incorrect. Any drugs are recommended to be used in isolation, in this case you need to use one of them.
In the absence of the effect of treatment or when signs of complications appear, you should contact the NSR. If within 60 minutes the pressure decreased by 15-20% of the initial high, then such an outcome is considered optimal. A higher rate of self-lowering blood pressure increases the risk of hypotension and crisis complications.
It is important to understand that these drugs for hypertensive crisis are used because they are the safest, although Captopril is contraindicated in pregnant and lactating women. "Nifedipine" can be used by pregnant women, but breastfeeding is recommended to be stopped. In the case of the use of Nifedipine by older people, it should be remembered that it is contraindicated in the presence of angina pectoris due to the fact that it can provoke the appearance of pain in an ischemic heart.
Tactics of the patient with conventional HA
In patients with a hypertensive disease with a critical course, the tactics of stopping HA is different and should be based on the recommendations of the attending physician. The crisis relief algorithm includes identifying symptoms, eliminating signs of a complicated crisis, and taking medications.
It is important that emergency care for hypertensive crisis is very dependent on the presence or absence of complications. If those are identified, then you must immediately contact the NSR. If there are no complications, hepatitis C can be stopped on its own with such drugs as Captopril, Nifedipine, Moxonidine, Clonidine, Propranolol.
Moxonidine tablets quickly reduce blood pressure after oral administration. But the maximum daily dose is only 0.6 mg.
Clonidine is even faster, but less secure. It is taken orally in half or 1 tablet. The dose is chosen independently depending on the current numbers of blood pressure and is based on the experience of previous use of the drug.
"Propranolol" is a drug that helps reduce blood pressure by lowering heart rate and cardiac output. It is contraindicated in the presence of asthma or moderate COPD, with atriofentricular blockade and with bradycardia, pregnancy and lactation. The tablets are taken orally and can only be combined with Nifedipine or Captopril.
“Moxonidine” can be taken together with “Captopril,” and “Clonidine” is not recommended to be combined with other drugs because of the risk of a strong decrease in blood pressure.
Frequent crises are a signal of an ineffective basic treatment regimen for hypertension. This means that either the wrong scheme of continuous therapy was not selected, or the patient deviates from the doctor's recommendations. In a condition such as an uncomplicated hypertensive crisis, treatment is considered effective if the symptoms gradually subside and disappear, and blood pressure decreases by about 20% per hour. The lack of effect from the measures taken or the deterioration of well-being is a signal that the intervention of the NSR is necessary.
SMP tactics for hypertensive crisis
Emergency care for a hypertensive crisis is often provided by the staff of the NSR and includes the following links: initial examination, identification of complaints and the nature of the increase in blood pressure, medical history, instrumental diagnostics (ECG), direct treatment, hospitalization or making an active visit.
The paramedic or SMP doctor determines the rate of increase in blood pressure, according to the condition of the patient, excludes or confirms the presence of complications of a hypertensive crisis, chooses the tactics of stopping it. Medicines that can be used to lower blood pressure are present in the standards of medical care for the NSR service. They have been proven to be effective and are safe for qualified use.
An SMP employee should tell his medical history: which drugs were most effective and which had insufficient effect. This will eliminate the appointment of drugs that are ineffective in a particular patient. A doctor or nurse practitioner often uses injectable drugs. Injections for hypertensive crisis are characterized by a high rate of blood pressure reduction and better control regarding dosing, and also allow you to effectively deal with most complications.
Intravenous antihypertensive drugs
In the injectable form, there are such drugs as “Magnesium sulfate 25%”, “Clonidine”, “Tahiben” or “Ebrantil”, “Furosemide”. The first can be used only in case of acute hypertensive encephalopathy and with eclampsia of pregnant women. "Clonidine" is a drug for the rapid reduction of high blood pressure, including in complicated crises. "Tahiben" and "Ebrantil" contain the drug urapidil, which stops both uncomplicated crises and complicated ones. The choice between Clonidine and urapidil preparations depends on the patient’s medical history and is left to the discretion of the medical professional.
Hypertension Statistics
According to medical statistics, more than half of people over 45 suffer from hypertension, and in 17-25% of them, due to irregular intake of drugs or ineffective therapy, hypertensive crises are observed more than once a quarter. And 7-11% of all hypertensive crises lead to complications that threaten the patient’s life directly. In men over 55 years old and women over 60 years old, the frequency of complicated crises is 12-16%, and from 75 years old - 30-35%.
Of 100 people over 45 years old, more than 50 suffer from hypertension, of which about 10 patients report the onset of a hypertensive crisis more than 1 time in 3 months, and in one of them the crisis is complicated. On a national scale, these are huge numbers, affecting which you can reduce the incidence of complications during crises and, accordingly, mortality. Therefore, to reduce the number of complications of hypertension, it is necessary to give clear instructions on the provision of emergency care for hypertensive crisis and the selection of the optimal patient tactics.