Hypertensive crisis: emergency versus urgency

A severely raised blood pressure is a crisis only by what it is doing to the organs, not by the number alone, so the nurse who finds one assesses at once for acute target-organ damage — headache with confusion, drowsiness, seizure or a new neurological deficit, chest pain or breathlessness with crackles, a change in vision, a falling urine output, and in a pregnant patient the picture of pre-eclampsia — and escalates on that assessment rather than reaching for a dose: with organ damage the pressure is a hypertensive emergency lowered with a titratable intravenous agent under continuous blood pressure and neurological monitoring by a controlled fraction in the first hour and then gradually over the following day, never to normal at once and never with a rapid-acting oral or sublingual agent, because the organs have adapted to the high pressure and a sudden drop starves the brain, heart and kidneys of the perfusion they were being protected from losing; without organ damage the same number is a hypertensive urgency that is brought down over days with oral drugs, a search for why it rose — missed doses, an abruptly stopped antihypertensive, a sympathomimetic drug, pain or a full bladder — and close follow-up, and the patient is watched through either course for the drowsiness, weakness, chest pain or falling urine output that mean the lowering has outrun the organs.