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. Episodes of a significant increase in blood pressure, regardless of the intensity of drug therapy, are called crises. Emergency care for a hypertensive crisis (HC) should be provided in a timely manner and in full to prevent serious complications.
Express diagnostics of hypertensive crisis
To determine the hypertensive crisis, it is enough to measure blood pressure. In the generally accepted interpretation, such a concept as GC includes a significant increase in blood pressure with the development of a specificsymptoms. There are no strict limits above which an increase in blood pressure is called a crisis. The main criterion is precisely the relationship between an increase in blood pressure and the onset of symptoms. Typical symptoms of uncomplicated HC requiring correction:
- pressive headaches;
- darkening of the eyes, redness of the face;
- flickering "flies" before the eyes;
- appearance of nausea, sometimes vomiting, pressure in the neck;
- tinnitus;
- sometimes feeling 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 increases, indicates the development of a crisis and the need for emergency care. Often in patients, high blood pressure values are not accompanied by any symptoms, especially in 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 GC complications
Standards of care for hypertensive crisis is 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 ventricularinsufficiency (OLZHN);
- acute hypertensive encephalopathy (AGE);
- acute cerebrovascular accident (ACV);
- myocardial infarction or acute coronary syndrome (MI or ACS);
- dissecting aortic aneurysm.
Each of these conditions is accompanied by specific symptoms and requires special care. To recognize them, you should remember some symptoms.
Symptoms of OLZHN, stroke, OGE
With OLZHN against the background of high blood pressure, there is a significant increase in shortness of breath, the development of first dry, and after a wet cough, a strong feeling of weakness. As the edema increases, bubbling breathing and a feeling of acute lack of air appear, a constant feeling of dissatisfaction with the breath. In the prone position, the patient is worse, when lowering the legs and sitting down, relief is achieved. Outwardly, cyanosis of the lips is easily noticeable, sometimes a grayish pale color of the skin of the legs with a bluish tint on the fingers, shins and feet.
The manifestations of OGE and stroke at the initial stage are almost the same, 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 limbs, loss of consciousness, impaired coordination, lowering of the corner of the mouth and development of facial asymmetry, less often swallowing disorder.
Myocardial infarction
More than 80% of myocardial infarctions occur against the background of high blood pressure. Therefore, in a crisisthe likelihood of its development increases. Symptoms of this are the appearance of strong pressing or burning pains in the projection of the heart, radiating to the left arm, under the left shoulder blade or to the interscapular region, sometimes to the region of the lower jaw. If such sensations are completely removed by taking nitroglycerin, we are talking about angina pectoris against the background of high blood pressure. But if the pain is not stopped by nitrates and lasts more than 30 minutes, the development of acute coronary syndrome or myocardial infarction cannot be ruled out.
Dissecting aortic aneurysm
In a dissecting aortic aneurysm, the specific symptom is pain, the intensity of which depends on pressure values. The higher it is, the more pronounced are the pain in the chest. They are in the nature of pressing or burning, reminiscent of those in a heart attack, but much more powerful. A specific symptom is the lack of response to nitrate intake. Also, if blood pressure decreases, pain also decreases significantly.
It is important to understand that a dissecting aneurysm is a formidable complication of a hypertensive crisis. But it will never occur in the absence of an aortic aneurysm. More importantly, if any of these symptoms occurs at the time of an increase in blood pressure, then the patient's standard algorithm of actions during a hypertensive crisis changes. Then, in a short time, you need to contact an ambulance about the complication of GC.
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. In a hypertensive crisis, the patient himself stops it. But if signs of complications appear or if self-treatment is ineffective, you should contact an ambulance or a hospital emergency room. This means that for any complications of a hypertension crisis, self-treatment should be excluded and specialized help should be sought. 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 for episodic GC
When symptoms of a hypertensive crisis are detected, treatment does not begin immediately. Initially, you should make sure that the blood pressure value is high or significantly exceeds the normal numbers, at which you previously felt comfortable. If the blood pressure is high, then you need to try to calm down, take a comfortable position (preferably lie down) and, after excluding the above complications, take the medications recommended by the doctor.
What to do with a hypertensive crisis, if it occurs for the first time or there are no medical recommendations? You need 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 drug that is contraindicated only in chronic renal failure, the development of allergies, pregnancy and lactation. It is taken sublingually: the tablet or part of it dissolves under the tongue. Its action begins in 7-10 minutesafter ingestion, and the peak occurs after 30 minutes.
When blood pressure rises 20 mmHg above normal, 12.5 mg should be taken, above 40 mmHg - 25 mg. If the drug is not effective enough, 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, you can take 5 mg, with an increase in blood pressure by 40 mmHg or more - 10 mg. The tablet dissolves under the tongue and works faster than Captopril. Admission may be accompanied by unpleasant, but safe side effects: reddening of the face and a feeling of heat in the cheeks and neck, redness of the sclera of the eyes.
These preparations are the easiest to provide emergency care for hypertensive crisis. They can be taken together, but this tactic is not correct for infrequent increases in blood pressure. Any drugs are recommended to be used in isolation, in this case, you need to use one of them.
If there is no effect from the treatment or if there are signs of complications, you should contact the EMS. If within 60 minutes the pressure has decreased by 15-20% of the initial high, then this 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 are used for hypertensive crisis because they are the safest, although Captopril is contraindicated in pregnant and lactating women. "Nifedipine" can also be used by pregnant women, but it is recommended to stop breastfeeding. In the case of the use of "Nifedipine" by the elderly, it should be remembered thatthat it is contraindicated in the presence of angina due to the fact that it can provoke the appearance of pain in the ischemic heart.
Patient management with habitual GCs
In hypertensive patients with a crisis course, the tactics of stopping GC is different and should be based on the recommendations of the attending physician. The crisis management algorithm includes identifying symptoms, ruling out 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 any are identified, then you must immediately contact the SMP. If there are no complications, GC can be stopped independently with such drugs as: Captopril, Nifedipine, Moxonidine, Clonidine, Propranolol.
Pills "Moxonidine" quickly reduce blood pressure after ingestion. But the maximum daily dose is only 0.6 mg.
"Clonidine" works even faster, but is less safe. It is taken orally in half or 1 tablet. The dose is chosen independently depending on the current BP numbers and is based on the experience of the previous use of the drug.
"Propranolol" is a drug that, by reducing heart rate and cardiac output, helps to reduce blood pressure. It is contraindicated in the presence of asthma or moderate COPD, atrioventricular block and bradycardia, pregnancy and lactation. The tablets are taken orally and can only be combined with Nifedipine or Captopril.
Moxonidine can be taken with"Captopril", and "Clonidine" is not recommended to be combined with other drugs due to 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 most correct scheme of permanent therapy has not been selected, or the patient allows deviations from the doctor's recommendations. In a condition such as 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 SMP is necessary.
SMP tactics in hypertensive crisis
Emergency care for a hypertensive crisis is often provided by EMS staff and includes the following links: initial examination, identification of complaints and the nature of the increase in blood pressure, drug history, instrumental diagnostics (ECG), direct treatment, hospitalization or registration of an active visit.
Paramedic or EMS doctor finds out the rate of increase in blood pressure, according to the patient's condition excludes or confirms the presence of a complication of a hypertensive crisis, chooses the tactics of its relief. Drugs that can be used to lower blood pressure are present in the standards of care for the EMS service. They are proven to work and are safe when used properly.
EMS worker should tell their drug history: which drugs were most effective and which hadinsufficient effect. This will eliminate the prescription of drugs that are ineffective in a particular patient. The doctor or paramedic of the EMS is more likely to use injectables. Injections for hypertensive crisis are distinguished by a high rate of blood pressure reduction and better dosing control, and also allow you to effectively deal with most complications.
Intravenous antihypertensive drugs
In the injectable form, there are drugs such as "Magnesium sulfate 25%", "Clonidine", "Tahiben" or "Ebrantil", "Furosemide". The first can only be used in case of acute hypertensive encephalopathy and 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 and complicated crises. The choice between Clonidine and urapidil preparations depends on the patient's drug history and is left to the discretion of the he althcare professional.
Hypertension statistics
According to medical statistics, more than half of people over 45 suffer from hypertension, and 17-25% of them have hypertensive crises more than once a quarter due to irregular medication or ineffective therapy. And 7-11% of all hypertensive crises lead to complications that directly threaten the patient's life. In men over the age of 55 and women over the age of 60, the frequency of complicated crises is 12-16%, and from 75 years old - 30-35%.
Out of 100 people over 45for more than 50 years suffer from hypertension, of which about 10 patients note the appearance of a hypertensive crisis more often than 1 time in 3 months, and in one of them the crisis is complicated. On a national scale, these are huge numbers, by influencing which it is possible to reduce the incidence of complications during crises and, accordingly, the mortality of the population. Therefore, in order to reduce the number of complications of hypertension, it is necessary to give clear instructions for providing emergency care in a hypertensive crisis and choosing the optimal patient tactics.
