Nurse Practitioner Expert Discusses Treatment for Malignant Hypertension

This case involves a 67-year-old woman who had a past medical history of hypertension and diabetes who presented to the emergency department with numbness on the left side of the body and blurred vision. Her blood pressure on arrival was abnormally high and she was started on a labetalol drip. Her blood pressure started to decline and she was transferred to the ICU, still on the labetalol drip. However, once the drip finished, her blood pressure started to climb again. A nitroglycerin drip was ordered and within minutes the patient’s blood pressure was reportedly normal. The nitroglycerin drip was immediately stopped, but her blood pressure once again started to climb. An MRI showed an acute temporal infarct.

Question(s) For Expert Witness

1. Can you opine on whether or not the DNP orders were deficient while acting under the supervision of a neurologist and evaluating the patient in the ED?

2. What is the standard of care for treating malignant hypertension?

3. Have you ever reviewed a similar case? If yes, please explain.

Expert Witness Response E-112134

There appears to be two strains of possible deviation from standard of care in this case. First, this patient should have been stroke coded or evaluated for Acute Ischemic Stroke. His medical history reads like a laundry list of risk factors for stroke. This patient, though hypertensive, is still presenting as an acute stroke first, with malignant hypertension as a secondary diagnosis. As to the malignant hypertension, it seems that the initial management with labetalol worked. I can't see a reason to stop that medication and start another. Once stroke is ruled out as the cause, the standard with treatment for malignant hypertension is to lower the blood pressure by 10-20% at most in the first hour, and then slowly over the next few days. As to those medications, nitroglycerine is not used in my practice for reduction of blood pressure in neurologic patients, it is only used for the management of chest pain in patients with suspected or proven coronary artery disease. Also, nitroprusside is the biggest gun in the arsenal when it comes to blood pressure lowering agents, and isn't normally administered as a "push" but rather as an infusion. I could expound on the different agents used.