pressure reduction with parenteral measures is not necessary but oral antihypertensives can be recommended. If there are symptoms, some of these will be confusion, seizures, stroke-like symptoms, shortness of breath, chest pain, and sometimes evidence of acute azotemia, such as nausea and lethargy. Fundoscopy will be crucial to the evaluation as well as a mental status evaluation, urinalysis, lung and heart examination, and jugular venous distention. Papilledema will be an early finding. Those with neurological symptoms need a CT of the head. ECG will show acute ischemia or ventricular hypertrophy. The goal is to reduce the mean arterial pressure by 20 to 25 percent in an hour or two using IV drugs like labetalol, nicardipine, nitroprusside, or fenoldopam. These drugs are helpful because they are titratable. It is not necessary to normalize the blood pressure acutely.
AIRWAY AND VENTILATION EMERGENCIES In most medical situations, except for cardiac arrest, airway management takes priority in an emergency setting. There are three steps. The first is clearing the upper airway of mucus or other obstruction. The second is using a mechanical device, such as an oropharyngeal airway or nasal airway to maintain an open passage. The third is assisting the patient in ventilations. Once ventilations are established, about six to eight milliliters per kilogram should be given per breath, along with a ventilatory rate of 8 to 10 breaths per minute. Even slower rates are recommended when air trapping is involved, such as COPD or asthma exacerbations. There are hemodynamic advantages to keeping the respiratory rate low. The head tilt-chin lift and jaw-thrust maneuvers will help maximize airway patency. In cases of possible cervical fracture, the jaw lift maneuver, which involves drawing the mandible forward, will help to open the airway. Dentures, blood, and secretions can be removed manually or can be removed through suction. A Magill forceps can remove deeper material.
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