What is the initial management for a patient with dizziness, vertigo, vomiting, abdominal pain, and severe hypotension, with a history of hypertension (HTN)?

Initial Management of Hypertensive Emergency with Gastrointestinal Symptoms

This patient requires immediate ICU admission for continuous blood pressure monitoring and parenteral antihypertensive therapy, as the combination of severe hypotension (paradoxically in a hypertensive patient), dizziness, vertigo, vomiting, and abdominal pain suggests a hypertensive emergency with acute target organ damage. 1, 2

Critical Initial Assessment

Determine if this is a true hypertensive emergency versus another acute condition:

• The presence of severe hypotension in a patient with hypertension history is paradoxical and concerning—this may indicate:

  • Acute aortic dissection (which can present with both hypertension and hypotension depending on affected vessels) 1, 2
  • Hypertensive crisis with subsequent cardiovascular collapse 1
  • Medication-induced hypotension after excessive antihypertensive use 3
  • Secondary cause such as pheochromocytoma crisis (which can cause dramatic BP fluctuations) 4

• Dizziness and vertigo in hypertensive patients are typically NOT caused by elevated blood pressure itself, but rather by hypotension (often iatrogenic from antihypertensive medications), concomitant neurological disease, or peripheral vestibular disorders 3

• Gastrointestinal symptoms (vomiting, abdominal pain) are recognized as frequent but non-specific symptoms of hypertensive emergencies, resulting from impaired cerebral autoregulation and visceral hypoperfusion 1

Immediate Diagnostic Priorities

Obtain these studies emergently to identify target organ damage:

• Hemoglobin and platelet count to assess for thrombotic microangiopathy 1, 2
• Creatinine, sodium, potassium, LDH, and haptoglobin to evaluate for acute kidney injury and hemolysis 1, 2
• Urinalysis with microscopy for proteinuria, hematuria, and casts indicating renal damage 1, 2
• ECG to detect ischemia, arrhythmias, or left ventricular hypertrophy 1, 2
• Troponin if any chest discomfort to rule out acute coronary syndrome 2
• CT angiography of chest and abdomen given the abdominal pain and hypotension—this is critical to exclude aortic dissection, which can present with these exact symptoms 1, 2
• Fundoscopy if malignant hypertension suspected (though less urgent than imaging) 1

Blood Pressure Management Strategy

The approach depends critically on current blood pressure and underlying pathology:

If Currently Hypertensive (>180/120 mmHg) with Hypotensive Episodes:

• Admit to ICU immediately for continuous arterial line monitoring 1, 2
• Target blood pressure reduction of 20-25% in the first hour, then cautiously to 160/100-110 mmHg over 2-6 hours 1, 2
• First-line IV agent: Nicardipine 5 mg/hr, titrating by 2.5 mg/hr every 15 minutes (maximum 15 mg/hr) for most hypertensive emergencies 2, 5
• Alternative: IV labetalol 20-80 mg bolus every 10 minutes, particularly if renal involvement suspected 1, 2, 4

If Aortic Dissection Confirmed:

• Aggressive BP lowering to SBP <120 mmHg and heart rate <60 bpm immediately 2
• Use esmolol plus nitroprusside or nitroglycerin as first-line therapy 1, 2

If Currently Hypotensive:

• Do NOT give antihypertensive medications 1
• Assess for volume depletion from pressure natriuresis, which commonly occurs in malignant hypertension and may require IV saline 1
• Rule out aortic dissection, acute MI, or other causes of shock 2
• Consider pheochromocytoma crisis if dramatic BP fluctuations present 4

Critical Pitfalls to Avoid

• Never use short-acting nifedipine—it causes unpredictable precipitous BP drops and is no longer acceptable for hypertensive emergencies 1, 6, 5
• Avoid excessive acute BP drops (>70 mmHg), which can precipitate cerebral, renal, or coronary ischemia 1, 2
• Do not assume elevated BP is the cause of symptoms—up to 78% of patients presenting with presumed "hypertensive crisis" actually have other conditions (stroke, Meniere's disease, tension headache) that cause reactive hypertension 3
• Do not treat BP numbers alone without confirming target organ damage—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 1, 2

Medication History Assessment

Immediately determine:

• Current antihypertensive regimen and recent changes 1
• Medication compliance (non-compliance is the most common cause of hypertensive emergencies) 1, 2
• Recent use of NSAIDs, steroids, sympathomimetics, or cocaine 1
• Possibility of medication overdose causing current hypotension 3

Post-Stabilization Management

Once acute crisis resolved:

• Screen for secondary hypertension causes (present in 20-40% of malignant hypertension cases): renal artery stenosis, pheochromocytoma, primary aldosteronism 1, 2
• Transition to oral therapy with combination of RAS blocker (ACE inhibitor or ARB) plus calcium channel blocker or thiazide diuretic 6, 2
• Address medication non-compliance if identified as trigger 2

The paradoxical presentation of hypotension in this hypertensive patient makes aortic dissection a life-threatening possibility that must be excluded immediately with CT angiography before any antihypertensive therapy is initiated. 1, 2