What is the management for an elderly lady with hypertension, presenting with headache, nausea, vomiting, loss of consciousness, and hyperglycemia?

Management of Elderly Patient with Hypertension, Headache, Nausea, Vomiting, Loss of Consciousness, and Hyperglycemia

This patient requires immediate ICU admission for suspected hypertensive emergency with possible hypertensive encephalopathy, given the combination of severe neurological symptoms (headache, nausea, vomiting, and two episodes of loss of consciousness) in a patient with known hypertension. 1

Immediate Assessment and Triage

Determine if this is a hypertensive emergency or urgency:

• The critical distinction is whether acute target organ damage is present, not the absolute BP value 1
• This patient has multiple red flags suggesting hypertensive emergency: headache, nausea, vomiting, and two episodes of loss of consciousness are recognized emergency symptoms indicating potential hypertensive encephalopathy or intracranial hemorrhage 2, 1, 3
• Loss of consciousness in the setting of severe hypertension indicates somnolence or lethargy that may precede seizures and coma in hypertensive encephalopathy 2
• The rate of BP rise is more important than the absolute value—even "normal" BP (110/60 mmHg) on presentation does not exclude a hypertensive emergency if the patient experienced severe elevations before arrival 2, 1

Essential Diagnostic Workup

Mandatory laboratory tests immediately:

• Complete blood count (hemoglobin, platelets) to assess for microangiopathic hemolytic anemia 1
• Comprehensive metabolic panel (creatinine, sodium, potassium) to evaluate renal function 1
• Lactate dehydrogenase (LDH) and haptoglobin to detect hemolysis in thrombotic microangiopathy 1
• Urinalysis for protein and urine sediment examination to identify renal damage 1
• Troponin if any chest discomfort to evaluate for acute coronary syndrome 1

Critical imaging studies:

• CT or MRI brain immediately to exclude intracranial hemorrhage, ischemic stroke, or hypertensive encephalopathy 2, 4
• MRI with FLAIR imaging is superior for detecting posterior reversible encephalopathy syndrome (PRES), which shows white matter lesions in posterior brain regions that are fully reversible with timely treatment 2, 4
• Unsteadiness and dizziness significantly increase the likelihood of intracranial pathology requiring immediate identification 4
• ECG to assess for cardiac involvement 1
• Fundoscopy to evaluate for malignant hypertension (retinal hemorrhages, cotton wool spots, papilledema) 1

Management of Hyperglycemia

Address the elevated glucose (217 mg/dl) as part of intercurrent illness management:

• Stressful events (including hypertensive crisis) frequently aggravate glycemic control and may precipitate diabetic ketoacidosis or nonketotic hyperosmolar state 2
• Any condition with marked hyperglycemia accompanied by vomiting or alteration in consciousness requires temporary adjustment of treatment and immediate interaction with the diabetes care team 2
• This patient may temporarily require insulin even if previously managed with diet or oral agents alone 2
• Ensure adequate fluid and caloric intake, as infection or dehydration is more likely to necessitate hospitalization in patients with diabetes 2
• Monitor blood glucose frequently during the acute illness 2

Blood Pressure Management Strategy

If hypertensive emergency is confirmed (target organ damage present):

• Admit to ICU immediately (Class I recommendation) for continuous BP monitoring and parenteral therapy 1
• First-line IV medication: Nicardipine at 5 mg/hr, titrate by 2.5 mg/hr every 15 minutes up to maximum 15 mg/hr 1
• Alternative: Labetalol 0.25-0.5 mg/kg IV bolus or 2-4 mg/min continuous infusion 1
• For suspected hypertensive encephalopathy specifically: Nicardipine is preferred because it leaves cerebral blood flow relatively intact and does not increase intracranial pressure 1

Target BP reduction:

• Reduce mean arterial pressure by 20-25% within the first hour 2, 1
• Then if stable, reduce to 160/100 mmHg over 2-6 hours 1
• Cautiously normalize over 24-48 hours 1
• Avoid excessive acute drops >70 mmHg systolic as this can precipitate cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation 2, 1

Critical Pitfalls to Avoid

• Do not dismiss the "normal" BP reading (110/60 mmHg) on presentation—patients with hypertensive emergencies may have fluctuating BP, and the history of loss of consciousness suggests prior severe elevations 2, 1
• Do not delay neuroimaging—focal neurological symptoms are rare in hypertensive encephalopathy and should raise suspicion of intracranial hemorrhage or ischemic stroke 2
• Do not use immediate-release nifedipine, hydralazine, or sodium nitroprusside unless other agents fail, due to unpredictable effects and potential risks 1
• Do not lower BP to "normal" acutely—this can cause ischemic complications in patients with chronic hypertension 1
• Do not ignore the hyperglycemia—it may worsen outcomes and requires concurrent management 2
• Do not rely solely on neurological examination—absence of focal deficits does not exclude hypertensive encephalopathy, PRES, or early stroke 4

Post-Stabilization Management

• Screen for secondary hypertension causes (renal artery stenosis, pheochromocytoma, primary aldosteronism) as 20-40% of malignant hypertension cases have secondary causes 1
• Address medication non-compliance, the most common trigger for hypertensive emergencies 1
• Transition to oral antihypertensive therapy with combination of RAS blockers, calcium channel blockers, and diuretics 1
• Arrange close follow-up to prevent recurrence 1