A 53-year-old man presents to the emergency department complaining of acute onset frontal headaches and intermittent dyspnea for the past day, along with long-term constipation associated with generalized abdominal pain. The patient reports a history of methamphetamine use and migraines. He states he does not have a primary care physician, and he does not take any medications. He reports he last used a large dose of methamphetamine yesterday. He denies dizziness, lightheadedness, blurry vision, change in hearing, neck pain, back pain, diaphoresis, chest pain, palpitations, orthopnea, trouble with urination, or change in bowel movement. His vital signs include blood pressure 230/119 mmHg, heart rate 132 beats/min, and respirations 28/min with oxygen saturation 99% on room air. On physical examination, the patient appears cachectic, anxious, and restless. He is tachypneic and tachycardic, but there are no other significant exam findings.
Laboratory findings as below:
Hemoglobin 12.8 g/dL, MCV 79
Platelets 389,000 mcl
Sodium 140 mEq/L
Potassium 4.8 mEq/L
BUN 32 mg/dL
Creatinine 2.3 mg/dL
Troponin 0.23 ng/ml
Creatine Kinase 1499 U/L
Urinalysis shows proteinuria. Electrocardiogram shows sinus tachycardia. Chest X-ray shows cardiomegaly, no infiltrates, no pleural effusion. CT head shows no acute hemorrhage. CT of the abdomen and pelvis shows diverticulosis and moderate fecal impaction. Echocardiogram is pending a final read.
Which of the following is the most appropriate next step in management?
A) Administer benzodiazepine for methamphetamine intoxication and monitor
B) Admit to the intensive care unit and start intravenous antihypertensives to a target of 130/80 mmHg today
C) Admit to the intensive care unit and start intravenous antihypertensives to a target of 160/100 mmHg today
D) Bolus intravenous fluids immediately for rhabdomyolysis
E) Start the patient on amlodipine 10 mg orally daily and metoprolol 50 mg orally twice a day for hypertension and tachycardia
C) Admit to the intensive care unit and start intravenous antihypertensives to a target of 160/100 mmHg today
This patient is presenting with hypertensive emergency with signs of kidney damage and cardiac injury, likely from substance use. Nonadherence to prescribed medications is the most common risk factor for hypertensive crisis, with hypertensive urgency defined as a blood pressure > 180/110-120 mmHg with no signs of end-organ damage; hypertensive emergency defined as blood pressure > 180/110-120 mmHg with findings of end-organ damage such as stroke, papilledema, acute coronary syndrome, acute heart failure, and acute kidney injury. Other precipitating factors for hypertensive crisis include substance use such as cocaine and methamphetamine such as in this patient. The goal is to decrease blood pressure by a maximum of 25% during the first hour of presentation, then to 160/100 mmHg by 2-6 hours.
Answer choice A:Administer benzodiazepine for methamphetamine intoxication and monitor, is incorrect. This patient’s clinical presentation is consistent with methamphetamine intoxication as he is showing signs of enhanced sympathetic activity. Treatment for methamphetamine intoxication includes benzodiazepine as the first-line therapy. However, the immediate next step should be initiation of anti-hypertensives along with benzodiazepine administration. Monitoring without additional intervention is not appropriate.
Answer choice B: Admit to the intensive care unit and start intravenous antihypertensives to a target of 130/80 mmHg today, is incorrect. Decreasing blood pressure too fast can cause potential cerebral ischemia which could lead to an acute stroke. Normalization of blood pressure should take place gradually within the next 2-3 days.
Answer choice D: Bolus intravenous fluids immediately for rhabdomyolysis, is incorrect. Although this patient meets criteria for rhabdomyolysis likely induced by stimulant use, intravenous fluids can further increase the patient’s blood pressure which is contraindicated at this time. Anti-hypertensives should be initiated first, once blood pressure is within an acceptable range as described above. Maintenance fluid could be started for this patient.
Answer choice E: Start the patient on amlodipine 10 mg orally daily and metoprolol 50 mg orally twice a day for hypertension and tachycardia, is incorrect. Hypertensive urgency could be managed by oral agents. However, hypertensive emergency should be managed as described above. Additionally, metoprolol should be avoided in stimulant-induced sinus tachycardia.
Key Learning Point
In patients with hypertensive emergency, blood pressure should be reduced by a maximum of 25% during the first hour of presentation, then to 160/100 mmHg by 2-6 hours. If appropriate, oral agents can be restarted at this time to target a normal blood pressure range in the next 2-3 days.
