med 18

 

hours with the use of oral antihypertensive medicines.

DISPOSITION

..... Admission

Admit all patients with hypertensive emergency to an

intensive care setting for careful titration of IV antihypertensives and close hemodynamic monitoring.

Table 1 8-3. Recommended agents for specific

hypertensive emergencies.

Diagnosis

Hypertensive

encephalopathy

Intracranial hemorrhage

Acute pulmonary edema

Suggested Agents

Nitroprusside

Fenoldopam

Labetalol

Nicardipine

Labetalol

Nitroglycerin loop diuretic

Nitroprusside

Acute coronary syndrome Nitroglycerin

Aortic dissection

Acute renal failure

..... Discharge

Labetalol

Esmolol AND nicardipine OR nitroprusside

Labetalol

Fenoldopam

Nicardipine

Severely hypertensive patients without evidence of acute

end-organ damage (ie, hypertensive urgency) can be safely

discharged with oral antihypertensive medications and

close outpatient follow-up.

HYPERTENSIVE EMERGENCIES

SUGGESTED READING

Cline DM, Machado AJ. Systemic and pulmonary hypertension.

In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 441-448.

Marik PE, Rivera R. Hypertensive emergencies: an update. Curr

Opin Grit Care. 201 1;17:569.

Marik PE, Varon J. Hypertensive crisis: challenges and management

Chest. 2007;131:1949.

Syncope

Trevor J. Lewis, MD

Key Points

• Place all patients with syncope on a cardiac monitor,

obtain a STAT bedside glucose level, and check conti nuous pulse oximetry.

• Obtain a detailed history of the events surrounding the

episode, including perti nent data from any available

bystanders such as family and emergency medical

service personnel.

INTRODUCTION

Syncope is defined as a transient loss of consciousness with

an inability to maintain postural tone. The event is classically followed by a spontaneous recovery to normal mentation. Between 12% and 48% of the U.S. population will

experience a syncopal episode at some point in their life ­

time. It is the presenting complaint in 1-3% of emergency

department (ED) visits and accounts for 1-6% of hospital

admissions. The etiology of syncope encompasses a wide

variety of disorders ranging from the benign to the acutely

life-threatening. Often the cause of syncope remains elusive within the ED. That said, a careful history and physical

exam combined with the appropriate ancillary testing will

help identify high-risk individuals who require hospital

admission for further work-up and management.

Syncope occurs secondary to impaired blood flow to

either the reticular activating system or the bilateral cere ­

bral hemispheres. Potential etiologies include transient

systemic hypotension or isolated central nervous system

(CNS) hypoperfusion (eg, subarachnoid hemorrhage).

The reduction in cerebral perfusion produces unconsciousness and a loss of postural tone. A reflexive sympathetic response combined with the recumbent positioning

of the patient results in restored cerebral perfusion and a

80