Hospital Patient With High Blood Pressure Dies After Premature Discharge

This case involved a 43-year-old female patient who presented to the emergency room following a motor vehicle accident. The patient complained of neck, shoulder, and hip pain. Upon exam, she was noted to have extremely high blood pressure. It was later discovered that the patient had not taken her antihypertensive medications. The patient was diagnosed with a muscle strain of the upper back and discharged home. One month later, the patient returned to the emergency room complaining of worsening back pain and spasms. Upon exam, she was noted to have paraspinal tenderness and spasms of the lumbar spine. Her blood pressure was also noted to be elevated. HEART scoring noted an elevated risk of adverse cardiac events. However, the patient was diagnosed with a muscle spasm of the back and discharged home. Several hours later, the patient was found in the emergency room parking lot unresponsive, apneic, and pulseless. The autopsy report noted the cause of death as cardiac tamponade due to a ruptured aortic aneurysm. An expert in emergency medicine was sough to review the patient’s medical record and opine on the care she received during the two emergency room visits prior to her death.

Question(s) For Expert Witness

1. How often do you evaluate patients who present to the emergency department with severe hypertension?

2. In patients who present with a hypertensive urgency or emergency, what are the most pertinent elements of the diagnostic workup and which criteria do you utilize to determine fitness for discharge?

Expert Witness Response E-374078

I evaluate severe hypertension about twice a shift, so 20-30 times per month. In patients who have a high blood pressure, pertinent elements of the work up are what other symptoms the patient is having and how indicative they are of end-organ damage (chest pain, urinary issues, headache, shortness of breath). Asymptomatic high blood pressure can be treated and discharged as long as the pressure is decreasing. You should not decrease a patient's blood pressure more than 20% in one visit unless there are obvious indications, such as a head bleed. I have indeed reviewed a case such as this multiple times in my role as medical director of two emergency departments. The case involved an individual who presented with chronic low back pain and happened to have high blood pressure due to not taking his medication. The patient was given his usual dose in the ED, the trend of his blood pressure was decreasing and he was discharged. He came back later for a different complaint, was found to have hypoxia due to pneumonia and COPD and still with high blood pressure as he still did not take his medication, was treated for pneumonia and admitted. The admitting physician was concerned about the high blood pressure not being aggressively treated, but did not know that is an inappropriate course of action.