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Managing Adult Medical Emergencies in the Dental Office
Hypertensive Emergency

Course Author(s): Palma A. Freydinger, DDS; Fady F. Faddoul, DDS, MSD

Hypertensive Emergency

Hypertension is defined as a blood pressure (BP) ≥140/90 mm Hg. Hypertensive emergency (Table 6) is defined by a BP ≥180/110 mm Hg and signs and symptoms of severely elevated BP. The mechanisms that lead to severely elevated BP appear to be related to a failure of normal autoregulatory function resulting in increased vascular resistance caused by endogenous vasopressors in patients with unrecognized or under-treated hypertension; and/or following the administration of sympathomimetic drugs such as high doses of epinephrine.

Table 6. Hypertensive Emergency.

Prevention:
  • Identify at-risk patient
    • Reduce anxiety
    • Ensure profound local anesthesia
      • Use local anesthetic agents containing a vasoconstrictor congruent with the patient’s functional capacity
Signs and symptoms:
  • Restlessness
  • Flushed face
  • Visual disturbances
  • Dyspnea
    • Pulmonary edema/congestive heart failure
  • A “hammering” pulse
  • Altered mental state
  • Chest pain
    • Myocardial ischemia, infarction, or aortic dissection
  • Seizure
    • Hypertensive encephalopathy
  • Cerebral hemorrhage, coma, death
Emergency response:
  • Place patient in an upright or semi-reclining position
    • Activate EMS
      • Administer oxygen
        • 4 to 6 L/min by nasal cannula
      • Monitor vital signs
        • If at any time the patient becomes unresponsive, no normal breathing, and no palpable pulse consider the diagnosis of cardiac arrest
          • Immediate CPR and defibrillation congruent with current recommendations
Nota bene:
  • In the oral healthcare setting, the BP should not be acutely lowered.
    • Tissue perfusion in the brain, heart, and kidneys is tightly regulated within a certain range of mean arterial pressure (MAP), abruptly decreasing the MAP can lead to significant drop in cerebral blood flow and, thus, cerebral ischemia.
  • Hypertensive urgency (BP ≥180/110 mm Hg, patient is asymptomatic)
    • Medical evaluation and risk modification within 24 to 48 hours - same day referral
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