Hypertensive Emergency with Headache and Visual Disturbance

Patient Information

Dispatch: A 52YO male presenting to the FAP at the Perth Royal Show complaining of a severe headache and blurred vision. (Marcus Holt)
Patient: Marcus Holt — 52yr (80kg)
Incident History: Pt has been at the show all day in the heat. Reports pounding headache that started approximately 90 minutes ago, now with blurred vision in both eyes. Admits he forgot to take his blood pressure tablets for the past two days.
Emergency Contact: Renee Holt (Wife) — 0412 447 883

Initial Rapid Assessment

Response: Alert
Airway: Patent. Self-maintaining. No obstruction, no stridor.
Breathing: Adequate. No increased work of breathing. Nil audible wheeze or crackles.
Circulation: Strong, bounding radial pulse. Skin warm and dry. No pallor. No external haemorrhage.
Disability: GCS 15 (E4V5M6). Alert and oriented to time, place and person. Complaining of severe bifrontal headache 9/10. Reports blurred vision bilaterally commenced approximately 20 minutes ago.
Exposure: No rashes or injuries visible. No signs of trauma.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	98% (RA)	Nil	16	94	228/142	<2s	15	4 4 ++	37.2	5.8 mmol/L	9
10 mins	98% (RA)	Nil	16	90	224/138	<2s	15	4 4 ++	37.2	5.8 mmol/L	9

History Taking

Treatment Response

Diagnosis

This patient is suffering from a hypertensive emergency (hypertensive crisis with end-organ involvement), presenting with markedly elevated blood pressure of 228/142 mmHg, severe headache, and bilateral visual disturbance consistent with hypertensive encephalopathy and possible hypertensive retinopathy. The missed antihypertensive medication over two days has precipitated this acute decompensation. This presentation carries a significant risk of neurological and cardiovascular deterioration including haemorrhagic stroke.

Facilitator Triggers — if trainees miss a critical step

! (If BP is not measured within the first 3 minutes of contact, Marcus begins rubbing his eyes and reports his vision is getting worse — prompt trainees: 'What observations are you prioritising right now?')
! (If trainees do not ask about medications or specifically about missed doses, Marcus volunteers: 'Come to think of it, I forgot my blood pressure tablets the last couple of mornings' — ensure trainees document this and recognise its clinical significance)
! (If trainees do not identify visual disturbance as an end-organ sign and attempt to discharge or downgrade the call, Marcus's GCS drops to 14 — E3V5M6 — and he becomes confused and asks where he is)
! (If trainees ask about chest pain and it is not addressed: Marcus confirms no chest pain, no arm weakness, no facial asymmetry — trainees should still document these as pertinent negatives given BP level)
! (If trainees consider administering GTN: facilitator prompts — 'What are the indications for GTN in the CPG? Does this presentation meet those criteria?' GTN is not indicated for isolated hypertension without cardiac chest pain — redirect to reassurance, positioning, oxygen if SpO2 warrants, and urgent transport.)

Treatment Objectives

1 Ensure scene safety and don appropriate PPE
2 Perform Primary Survey — confirm patent airway, adequate breathing, bounding pulse, no haemorrhage
3 Position patient seated or semi-recumbent in a position of comfort — do NOT lay flat as this may worsen cerebral perfusion pressure
4 Perform full Vital Sign Survey — obtain blood pressure (both arms if possible), pulse, RR, SpO2, GCS, BGL, temperature, pain score, and PERL
5 Document BP of 228/142 mmHg — recognise this as a hypertensive emergency with end-organ involvement (neurological symptoms: severe headache + visual disturbance)
6 Assess and document GCS 15 (E4V5M6) — orientated to time, place and person
7 Administer Oxygen ONLY if SpO2 drops below 94% — current SpO2 98% (RA), oxygen is NOT indicated at this time; do not administer unnecessary supplemental oxygen. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
8 Perform Secondary and CNS Survey — assess pupils (PERL 4mm bilaterally), check for facial droop, arm drift, speech difficulty, neck stiffness; document all findings including pertinent negatives
9 Elicit full IMISTAMBO history — specifically identify missed antihypertensive medications (Amlodipine 10mg, missed 2 days) as precipitating factor
10 Reassess BP, GCS, and visual symptoms every 5 minutes — this is a time-critical presentation
11 Recognise this presentation is OUTSIDE EHS pharmacological scope — there are NO EHS-authorised medications to treat hypertensive emergency; management is supportive (reassurance, positioning, monitoring) pending urgent ambulance transport
12 Provide continuous reassurance — keep patient calm and still to minimise sympathetic stimulation
13 Minimise patient's exertion — do not allow Marcus to walk; keep him seated at the FAP
14 Contact CSP immediately to arrange urgent ambulance — IMISTAMBO handover to CSP — document time-critical status
15 Monitor for deterioration: falling GCS, onset of vomiting, seizure activity, focal neurological deficit, or chest pain — manage complications as per relevant CPGs if they arise
16 Prepare for potential GCS deterioration — have OPA, suction, BVM and oxygen ready at FAP
17 Scenario ends on arrival of ambulance and IMISTAMBO handover
18 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Stroke (Cerebrovascular Accident) · Unconsciousness · Chest Pain / Acute Coronary Syndrome · Autonomic Dysreflexia · Primary Survey · Secondary & CNS Survey · Blood Pressure · Glasgow Coma Scale (GCS) · Pulse Oximetry · Oxygen Delivery

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