How should I initially manage an adult patient presenting with vomiting, diarrhea, dizziness and markedly elevated blood pressure?

Management of Acute Vomiting, Diarrhea, Dizziness, and Elevated Blood Pressure

This patient requires immediate assessment for hypertensive emergency with volume depletion—admit to the ICU if acute target-organ damage is present, or manage as hypertensive urgency with oral rehydration and gradual blood-pressure reduction if organ damage is absent.

Immediate Triage: Hypertensive Emergency vs. Urgency

The critical first step is determining whether markedly elevated blood pressure (>180/120 mmHg) is accompanied by acute target-organ damage 1. The presence or absence of organ injury—not the absolute BP value—dictates management 1.

Rapid Bedside Assessment for Target-Organ Damage

Perform a focused evaluation within minutes 1:

• Neurologic: Check for altered mental status, severe headache with vomiting, visual disturbances, seizures, or focal deficits suggesting hypertensive encephalopathy or stroke 1
• Cardiac: Assess for chest pain, dyspnea with pulmonary edema, or signs of acute left-ventricular failure 1
• Fundoscopy: Look for bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy) indicating malignant hypertension 1
• Renal: Evaluate for oliguria or acute rise in creatinine 1
• Laboratory panel: Obtain hemoglobin, platelets, creatinine, electrolytes, LDH, haptoglobin, urinalysis, and troponin to detect thrombotic microangiopathy or cardiac injury 1

Concurrent Volume Depletion Assessment

This patient has vomiting and diarrhea causing fluid and electrolyte losses that complicate hypertensive management 2. Assess for moderate-to-severe volume depletion using the following signs—four or more indicate significant depletion 2:

• Confusion or non-fluent speech 2
• Extremity weakness 2
• Dry mucous membranes, dry tongue, or furrowed tongue 2
• Sunken eyes 2
• Postural dizziness (inability to stand) or postural pulse change ≥30 bpm 2

Management Algorithm

If Hypertensive Emergency (Target-Organ Damage Present)

Admit to ICU immediately with continuous arterial-line monitoring (Class I recommendation) 1.

Blood-Pressure Reduction Strategy

• First hour: Reduce mean arterial pressure by 20-25% (or systolic ≤25%) 1
• Hours 2-6: Lower to ≤160/100 mmHg if stable 1
• Hours 24-48: Gradually normalize blood pressure 1
• Avoid systolic drops >70 mmHg to prevent cerebral, renal, or coronary ischemia 1

First-Line IV Medications

• Nicardipine (preferred for most emergencies): Start 5 mg/h, titrate by 2.5 mg/h every 15 minutes to maximum 15 mg/h 1. Nicardipine preserves cerebral blood flow and does not raise intracranial pressure 1
• Labetalol (alternative): 10-20 mg IV bolus over 1-2 minutes, repeat or double every 10 minutes (max cumulative 300 mg) 1. Contraindicated in reactive airway disease, heart block, bradycardia, or decompensated heart failure 1

Volume Repletion in Emergency Setting

Administer isotonic fluids intravenously to correct volume depletion while simultaneously lowering blood pressure 2. Volume depletion from pressure natriuresis may occur, and IV saline may be needed to prevent precipitous BP falls 1.

If Hypertensive Urgency (No Target-Organ Damage)

Manage as outpatient with oral medications and follow-up within 2-4 weeks—hospitalization is not required 1.

Blood-Pressure Reduction Strategy

• First 24-48 hours: Gradually reduce to <160/100 mmHg 1
• Subsequent weeks: Aim for <130/80 mmHg 1
• Avoid rapid BP lowering to prevent hypoperfusion-related injury 1

Preferred Oral Agents

• Extended-release nifedipine 30-60 mg once daily 1
• Captopril 12.5-25 mg orally (use cautiously in volume-depleted patients) 1
• Labetalol 200-400 mg orally (avoid in reactive airway disease, heart block, or bradycardia) 1

Volume Repletion in Urgency Setting

Administer oral rehydration solution or isotonic fluids orally 2. Increase fluid intake with limited caffeine and consider electrolyte replacement solutions 2. If unable to tolerate oral fluids, consider nasogastric or subcutaneous isotonic fluids 2.

Management of Vomiting and Diarrhea

Sick Day Medication Guidance

Temporarily stop these medications during acute illness with vomiting/diarrhea 2:

• ACE inhibitors/ARBs (e.g., perindopril, candesartan) 2
• Diuretics (loop, thiazide, potassium-sparing) 2
• NSAIDs 2

When to Seek Emergency Care

Contact healthcare provider immediately if 2:

• Vomiting >4 times in 12 hours or cannot keep fluids down 2
• Reduced level of consciousness or new confusion 2
• Low blood pressure (SBP <80 mmHg; drop of 20 mmHg in SBP or 10 mmHg in DBP) 2
• Increased heart rate (increase by 30 bpm) 2

Self-Management Criteria

Self-management is appropriate when 2:

• Absence of severe symptoms 2
• Patient feels able to cope 2
• Patient can keep up with fluid intake 2

Seek assistance when 2:

• Patient feels not coping 2
• Symptoms have not resolved within 72 hours 2
• Cannot keep up with intake of foods or fluids 2

Critical Pitfalls to Avoid

• Do not admit patients with severe hypertension without evidence of acute target-organ damage 1
• Do not use immediate-release nifedipine—it can cause unpredictable precipitous drops, stroke, and death 1
• Do not rapidly lower BP in hypertensive urgency—this may cause hypoperfusion injury 1
• Do not assume absence of symptoms equals absence of organ damage—a focused exam including fundoscopy is essential 1
• Do not treat the BP number alone—many patients with acute pain or distress have transient elevations that resolve when the underlying condition is treated 1
• Do not overlook volume depletion—up to one-third of patients with elevated BP normalize before follow-up, and rapid BP lowering may be harmful 1

Post-Stabilization Considerations

• Screen for secondary hypertension causes after stabilization—20-40% of malignant hypertension cases have identifiable etiologies (renal artery stenosis, pheochromocytoma, primary aldosteronism, renal parenchymal disease) 1
• Address medication non-adherence—the most common precipitating factor for hypertensive emergencies 1
• Schedule monthly follow-up until target BP <130/80 mmHg is achieved and organ-damage findings regress 1