HYPERTENSIVE CRISIS

HYPERTENIC CRISIS with a sharp increase in blood pressure (diastolic, as a rule, exceeds 120 mm Hg) is an exacerbation of the symptoms inherent in hypertension. For her, as well as for many other diseases, there are periodic exacerbations, worsening of the condition, followed by remissions, often even without treatment. However, periods of exacerbation that last for weeks, months, should not be called crises: the latter are more correctly attributed only to fast, sometimes sudden, short-term (minutes, hours, less often - days) deterioration, accompanied by a marked rise in blood pressure, severe subjective symptoms and objective signs of acute Neurohumoral disorders.

The rise of blood pressure can be caused by two mechanisms: 1) vascular - an increase in the overall peripheral resistance due to an increase in vasomotor (neurohumoral effects) and basal (with sodium retention) arteriolar tone; 2) cardiac - increased cardiac output due to increased heart rate, volume of circulating blood, contractility of the myocardium.

In the clinical picture of the crisis, the symptoms associated with a sharp increase in blood pressure (the speed of the increase in pressure - minutes or hours, but not a day) is of primary importance. As a rule, both systolic and diastolic pressure rises, but in different degrees, therefore pulse pressure can increase and decrease.

With hypertensive crises, the headache increases dramatically or appears. It can be paroxysmal and permanent, blunt and pulsating, can be localized in the back of the neck, crown or forehead and is caused most often by cerebral blood supply disorders. Dizziness , loss of balance, a feeling that "everything is swimming around" are also frequent complaints of patients during a crisis. Often, headache and dizziness are combined with noise in the ears. The brain symptoms of the crisis include nausea and vomiting . The combination of these with a headache with a severe general condition of the patient may indicate an increase in intracranial pressure and the development of cerebral edema. Visual impairment often accompanies the development of the crisis and is a consequence of changes in the fundus of the eye (vascular spasm of the retina, edema of the optic discs). The degree of vision disorders can be different: from a grid of dark or light moving points in front of the eyes to short-term vision loss.

To frequent complaints of patients during the hypertensive crisis include unpleasant sensations in the heart: pain, palpitations, interruptions, shortness of breath . The pains may be aching, stitching (as cardialgia), but often have the character of typical intense compressive chest pains that give off to the left arm, a scapula that decrease after taking nitroglycerin, and indicate the onset of an angina attack. Less common are complaints of abdominal pain ("abdominal toad") and a symptom of intermittent claudication as manifestations of vascular disorders in other organs.

Examination of the patient allows us to identify a number of symptoms characteristic of the crisis. At the forefront are signs of impaired activity of the central and autonomic nervous system. Patients are nervous, irritable, skin moist, hyperemic. Often, red spots appear on the face, neck, and chest; There are chills, muscle trembling, the temperature rises to subfebrile figures. In other cases, on the contrary, there is obviously a sharp depression of the nervous system: lethargy, deafness, drowsiness. There may be muscle twitching and even epileptiform cramps , between attacks of which the patient is in a coma. Speech disorders, one-sided weakness and loss of pain sensitivity (in more light cases, the sensation of crawling, tingling in the hands and feet - the so-called paresthesia) in the right or left extremities indicate transient focal disturbances in the central nervous system.

Mandatory manifestation of hemodynamic. Violations in a crisis is only an increase in blood pressure. The rest of the picture of the cardiovascular pathology is diverse. Pulse is often accelerated, but the feeling of palpitation may not be accompanied by tachycardia. Sometimes there is a bradycardia . Of the disturbances of the rhythm more often than others, extrasystole occurs. Percutaneous boundaries of relative dullness of the heart, as a rule, widened to the left due to hypertrophy of the left ventricle, observed with prolonged arterial hypertension. Auscultation is marked by a sharp accent, sometimes a splitting of the second tone over the aorta. If the hypertensive crisis occurs in a patient with severe cardiac changes of the heart, it is often possible to detect signs of acute cardiac insufficiency: the pulse becomes frequent, and the heart sounds deaf, in the lower parts of the lungs begin to hear inaudible stagnation rales - an attack of cardiac asthma develops, in severe cases, pulmonary edema More often there is a left-ventricular failure). On the ECG during the hypertensive crisis, there may be signs of a systolic overload of the left ventricle as a depression of the ST segment and a flattening of the T wave.

The various symptoms noted are often combined, causing the emergence of characteristic symptom complexes, which makes it possible to distinguish between two types of crises.

Crises of the first type (hyperkinetic) are observed mainly in the early stages of arterial hypertension, develops sharply, accompanied by excitation of patients, an abundance of "vegetative signs" (muscle tremor, increased sweating, red spots on the skin, palpitations, by the end of the polyuria crisis, sometimes abundant loose stools) And flow for a short time (no more than 3 - 4 hours). These crises are characterized by a predominant increase in systolic blood pressure, an increase in pulse pressure, an increase in heart rate. Crises of the first type are characterized by the prevalence of adrenaline in the blood, which, as is known, has the ability to increase metabolism, cause hyperglycemia, tachycardia, and systolic pressure.

Crises of the second type (hypokinetic), which usually arise in the late stages of the disease against a background of a high initial level of blood pressure, are characterized by a less acute onset, a more gradual development, a relatively long period (from several hours to four to five days) and severe course. These patients look sluggish, inhibited. Brain and heart symptoms are especially pronounced in them. The systolic and diastolic pressure in these cases is very high, but the diastolic pressure rises, so the pulse pressure decreases somewhat. Tachycardia is not present or it is expressed slightly. For crises of the second type, there is a predominance of norepinephrine in the blood, which primarily increases the peripheral vascular resistance and, accordingly, the diastolic pressure.

Of course, the subdivision of hypertensive crises into two species is to a certain extent conditional: often the crisis proceeds with clinical signs, some of which are characteristic for the first species, and the other part for the second.

Possible complications: hypertensive encephalopathy, cerebral edema, characterized by headache, nonsystemic dizziness, severe nausea and vomiting, convulsions, confusion, coma; Acute violation of cerebral circulation with the appearance of focal neurological disorders; Eclampsia , the appearance of convulsive syndrome; Development of heart failure; The development of an attack of angina pectoris or myocardial infarction; Exfoliation of the aortic aneurysm.

Thus, the diagnosis of the hypertensive crisis is based on the following main criteria:

1)

Relatively sudden onset;

2)

Individually high recovery of blood pressure;

3) subjective disorders and objective symptoms of cerebral, cardiac and vegetative nature.

The hypertensive crisis is attributed to conditions that pose an immediate threat to the life of the patient and require urgent therapy. The initial goal of the treatment is to reduce the diastolic pressure to 100 mmHg. With vertebrobasilar insufficiency and signs of cerebral ischemia against a background of hypertensive crisis, blood pressure should be lowered cautiously due to the danger of cerebral circulation disorders. Since the pressure decrease nevertheless can be sharp, the patient should be in a horizontal position.

Currently, there is a sufficient range of products for rapid reduction in blood pressure. Therapy of an uncomplicated crisis is advisable to begin with taking 10 - 20 mg of nifedipine (Corinfar) under the tongue. In most cases, after 5 to 30 minutes, a significant drop in blood pressure begins (by 20-25%) and the patients feel better. If there is no effect, you can repeat nifedipine. The duration of action of the drug so taken is 4-5 hours. In the hyperkinetic version of the crisis, 20-40 mg of anaprilin is administered to the tongue (intravenous administration is possible provided that the blood pressure and heart rate are monitored in a specialized department). From distracting procedures apply mustard plasters on the back of the head, on the lower back and to the feet, cold to the head with severe headaches, hot foot baths.

Parenteral administration of drugs is indicated when developing against a background of hypertensive crisis of encephalopathy, eclampsia, heart failure or myocardial infarction, with exfoliating aortic aneurysm, as well as ineffective reception of nifedipine under the tongue. Since the clinical picture of hypertensive crises and their complications is diverse, various symptomatic agents are also used.

At the expressed excitation of patients the preparations showing calming and hypnotic action are shown: droperidol (2 ml of 0.25% solution intravenously struino), seduxen (10 mg - 2 ml intramuscularly or intravenously). Seduxen is especially indicated in the complication of the hypertensive crisis by the development of convulsive syndrome.

At the expressed neurologic symptomatology expediently application of dibazolum (5-10 ml of 0,5% solution) and magnesium sulphate. The latter has a vasodilating, sedative, anticonvulsant effect, reduces cerebral edema. Since a rapid therapeutic effect is required, the drug is administered intravenously slowly (elderly patients are especially cautious, since breathing disorders are possible) at a dose of 10-15 ml of a 25% solution. Intramuscular administration is undesirable not only because of low efficiency, but also because of the high risk of developing abscesses. Euphyllin (10 ml of a 2.4% solution intravenously stratified or drip) is also indicated for complications of crisis by cerebral disorders. The drug lowers blood pressure and stimulates the central nervous system, has a moderate diuretic effect. Elderly patients are administered with caution because of the possibility of increasing the heart rate and the development of arrhythmias.

A good hypotensive effect due to intensive elimination of sodium chloride is provided by diuretics. Their use is especially indicated in the picture of cerebral edema or acute left ventricular failure accompanying the crisis. Lasix (furosemide) is administered intravenously (2 - b ml), furosemide - 40 mg under the tongue. Diuretics do not replace, but supplement and enhance the action of other antihypertensive drugs.

In the case of a hypertensive crisis complicated by severe angina, the development of myocardial infarction or acute left ventricular failure, sublingual or intravenous drip nitrate (nitroglycerin or isosorbide-dinitrate) is indicated.

Treatment of hypertensive crisis provides, in addition to the use of effective antihypertensive drugs, distracting procedures, soothing and symptomatic therapy, creating a patient full physical and mental rest. Since immediate introduction of drugs lowering blood pressure is required, treatment begins where it is diagnosed: at a medical station, at home, in an ambulance, in the emergency room. For the first time in the life of a hypertensive crisis that has arisen, if it is complicated by its course, and also when it is impossible to provide full-fledged medical assistance on site, the patient should be hospitalized urgently: maximum rest is only a background for active therapy.