What is the best course of action for a patient with a recent hypertensive emergency, ongoing confusion, but no vomiting or focal deficits, who has been discharged home?

This Patient Should NOT Have Been Discharged Home

A patient with recent hypertensive emergency who has ongoing confusion requires immediate return to the emergency department for neuroimaging and ICU admission, regardless of the absence of vomiting or focal deficits. 1

Why This Discharge Was Inappropriate

Confusion Indicates Potential Hypertensive Encephalopathy

• Confusion alone represents acute neurologic target organ damage and is a cardinal feature of hypertensive encephalopathy, which can progress to somnolence, lethargy, seizures, cortical blindness, and loss of consciousness. 1

• Focal neurological lesions are actually RARE in hypertensive encephalopathy—their absence does not exclude this diagnosis and should not provide false reassurance. 1

• The absence of vomiting is irrelevant; while vomiting can occur with hypertensive encephalopathy, confusion alone mandates urgent evaluation. 1, 2

Critical Diagnostic Evaluation Required Immediately

Brain imaging must be obtained urgently to differentiate between:

• Hypertensive encephalopathy/PRES (posterior reversible encephalopathy syndrome)—which shows white matter lesions in posterior brain regions on MRI with FLAIR imaging that are fully reversible with timely treatment 1

• Intracranial hemorrhage—which CT scan is useful to exclude 1

• Ischemic stroke—which requires different blood pressure management targets 1, 3

MRI with FLAIR imaging is superior to CT for detecting hypertensive encephalopathy and should be obtained if available, though CT is essential first to exclude hemorrhage. 1, 4

Mandatory Laboratory and Diagnostic Workup

The following tests should be obtained immediately upon return to the ED: 1, 3

• Complete blood count (hemoglobin, platelets) to assess for thrombotic microangiopathy
• Comprehensive metabolic panel (creatinine, sodium, potassium, LDH, haptoglobin)
• Urinalysis with microscopy for protein, erythrocytes, leukocytes, cylinders
• ECG to assess for cardiac involvement
• Fundoscopy to evaluate for malignant hypertension with retinal hemorrhages, cotton wool spots, or papilledema

Immediate Management Upon Return to Hospital

ICU Admission is Mandatory

This patient requires ICU admission (Class I recommendation, Level B-NR) for continuous blood pressure monitoring and parenteral antihypertensive therapy. 1, 3

Blood Pressure Management Strategy

If hypertensive encephalopathy is confirmed:

• Reduce mean arterial pressure by 20-25% within the first hour using IV antihypertensives 1, 3

• Target blood pressure of 160/100 mmHg over the next 2-6 hours if stable 1, 3

• Cautiously normalize blood pressure over 24-48 hours 1, 3

Critical pitfall to avoid: Do not reduce blood pressure to "normal" acutely—patients with chronic hypertension have altered cerebral autoregulation and acute normalization can cause cerebral, renal, or coronary ischemia. Avoid drops >70 mmHg systolic. 1, 3

First-Line Medication Selection

Nicardipine is the preferred agent for hypertensive encephalopathy because it maintains cerebral blood flow and does not increase intracranial pressure: 3

• Initial dose: 5 mg/hr IV infusion
• Titrate by 2.5 mg/hr every 15 minutes
• Maximum dose: 15 mg/hr

Labetalol is an acceptable alternative: 3

• 0.25-0.5 mg/kg IV bolus over 1-2 minutes, OR
• 2-4 mg/min continuous infusion until goal BP reached, then 5-20 mg/hr maintenance

Avoid these medications: 3

• Immediate-release nifedipine (unpredictable precipitous drops, reflex tachycardia)
• Hydralazine (unpredictable response, prolonged duration)
• Sodium nitroprusside (use only as last resort due to cyanide toxicity risk)

Why Confusion Cannot Be Dismissed

Subtle Neurologic Symptoms Progress Rapidly

• Confusion and altered mental status are early manifestations that can rapidly progress to seizures and coma if untreated. 1, 2

• The rate of blood pressure rise is more important than the absolute value in causing encephalopathy—even "normal" blood pressure on presentation doesn't exclude prior severe elevations that caused brain injury. 1

Mortality Risk Without Treatment

Hypertensive emergencies carry a 1-year mortality rate >79% and median survival of only 10.4 months without proper treatment. 3

Post-Stabilization Management

After acute stabilization and resolution of confusion: 3

• Screen for secondary hypertension causes (present in 20-40% of malignant hypertension cases): renal artery stenosis, pheochromocytoma, primary aldosteronism

• Address medication non-adherence (the most common trigger)

• Transition to oral antihypertensive regimen with combination therapy (RAS blocker, calcium channel blocker, diuretic)

• Target blood pressure <130/80 mmHg for most patients

• Frequent follow-up (at least monthly) until target BP reached and organ damage regressed