What is the management of severe hypertension (blood pressure 200/120 mmHg) with epistaxis (nasal bleeding) in the emergency room (ER)?

Management of Severe Hypertension (BP 200/120) with Epistaxis in the Emergency Room

This patient does NOT have a hypertensive emergency unless there is evidence of acute end-organ damage beyond the nosebleed itself; epistaxis alone is not considered acute target organ damage, so this should be managed as a hypertensive urgency with oral antihypertensive agents and local control of bleeding. 1

Initial Assessment: Emergency vs Urgency

• Determine if true hypertensive emergency exists by evaluating for acute end-organ damage including hypertensive encephalopathy, acute stroke, acute myocardial infarction, acute heart failure with pulmonary edema, acute renal failure, or aortic dissection 1
• Epistaxis by itself does NOT constitute acute target organ damage and does not warrant IV antihypertensive therapy 1
• Patients lacking acute hypertension-mediated end organ damage can be treated with oral BP-lowering agents and discharged after brief observation 1, 2

Blood Pressure Management Strategy

For Hypertensive Urgency (No End-Organ Damage)

• Reduce systolic BP by no more than 25% within the first hour, then if stable, aim for BP <160/100 mmHg within the next 2-6 hours, and cautiously normalize over 24-48 hours 1, 2
• Use oral antihypertensive medications as first-line therapy 2
• First-line oral agents include:
  • Captopril (ACE inhibitor) 2
  • Labetalol (combined alpha and beta-blocker) 2
  • Extended-release nifedipine (calcium channel blocker) 2
• Observe patient for at least 2 hours to evaluate BP-lowering efficacy and safety 2

If True Hypertensive Emergency Exists

• Admit to intensive care unit for continuous BP monitoring and parenteral antihypertensive therapy 1
• Use IV labetalol as first-line agent: 0.25-0.5 mg/kg IV bolus, followed by 2-4 mg/min continuous infusion until goal BP reached, then 5-20 mg/h maintenance 1, 2
• Alternative IV agents include nicardipine (initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h) or clevidipine 1

Local Management of Epistaxis

• Apply topical vasoconstrictors such as oxymetazoline or phenylephrine on cotton pledget to the bleeding site 1
• 65-75% of patients achieve resolution with oxymetazoline alone 1
• Perform nasal cautery (chemical or electrical) under local anesthesia if bleeding site is identified and accessible 1
• After bleeding stops, use moisturizing and lubricating agents to prevent recurrence 1

Critical Pitfalls to Avoid

• Do NOT use immediate-release nifedipine for hypertensive urgency due to unpredictable BP drops and adverse outcomes 3, 4
• Avoid rapid BP reduction as this can cause cardiovascular complications and end-organ hypoperfusion 1, 2
• Do NOT use sodium nitroprusside except as last resort due to cyanide toxicity risk 3, 4
• Be aware that topical vasoconstrictors may cause systemic hypertension, though studies show minimal effect on mean arterial pressure in patients without cardiovascular disease 1

Disposition and Follow-Up

• Most patients with hypertensive urgency and epistaxis can be discharged after brief observation once BP is controlled and bleeding stopped 1, 2
• Address medication adherence issues, as many hypertensive urgencies result from non-compliance 2
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 1, 2
• Ensure patient has appropriate oral antihypertensive regimen before discharge 2