From the Guidelines
The patient with severe hypertension, tachycardia, and post-seizure altered mental status should be treated as a hypertensive emergency and requires immediate and careful intervention to reduce blood pressure, often with intravenous therapy 1.
Key Considerations
- The patient's symptoms, including altered mental status and post-seizure condition, suggest hypertensive encephalopathy, which is a life-threatening condition that requires prompt treatment 1.
- The goal of treatment is to rapidly reduce blood pressure to prevent further organ damage, while also managing the patient's altered mental status and seizure activity 1.
- Intravenous antihypertensive agents, such as nitroglycerin, nitroprusside, or nicardipine, may be used to rapidly lower blood pressure, and should be titrated to achieve a target blood pressure reduction of 10-15% in the first hour 1.
- Additionally, the patient may require seizure prophylaxis and close monitoring of their neurological status, as well as cardiac and renal function 1.
- It is also important to investigate and manage any underlying causes of the hypertensive emergency, such as renal disease or cardiovascular conditions 1.
From the Research
Management of Severe Hypertension and Post-Seizure Altered Mental Status
The management of a patient with severe hypertension, tachycardia, and post-seizure altered mental status requires careful consideration of the underlying cause of the hypertension and the potential risks and benefits of blood pressure management.
- The optimal blood pressure target for patients with acute ischemic stroke is not well established, but guidelines recommend values of blood pressure < 185/110 mmHg in patients treated with intravenous t-PA and "permissive hypertension" up to 220/120 mmHg in those not treated with intravenous t-PA 2.
- In patients undergoing mechanical thrombectomy, the guidelines recommend a blood pressure < 185/110 mmHg before thrombectomy, and a blood pressure < 180/105 mmHg during and after thrombectomy 2.
- However, some studies suggest that the primary goal during thrombectomy should be to prevent significant low blood pressure, with a target systolic blood pressure > 140 mmHg or MAP > 70 mmHg, and after thrombectomy, the primary goal should be to prevent high blood pressure, with a target systolic blood pressure < 160 mmHg or MAP < 90 mmHg 2.
- Clonidine may be used for acute management of hypertension in hospitalized older people, but its use is associated with potential adverse reactions, including stroke and falls 3.
- The relationship between presenting blood pressure in acute ischemic stroke patients and outcome is complex, with worse outcomes when blood pressure is high or low, and the optimal blood pressure target is less clear in patients undergoing mechanical thrombectomy 4, 2.