Hypertensive crisis in the practice: recognize and act

Blood pressure is one of the cheapest and most neglected pieces of clinical information in an orofacial harmonization (HOF) practice. Many patients are hypertensive and do not know it, others know and do not take their medication properly, and others have a pressure spike from anxiety in the moment. In every case, measuring before the procedure helps identify the risk and decide whether it is the right day.

This page covers recognition and initial management of very high blood pressure, with or without symptoms, at the level of practice organization. It does not recommend drugs or doses, and it does not replace current medical guidelines or the assessment of a qualified professional.

Why does blood pressure matter in HOF?

A few practical reasons:

• Bruising: high pressure can increase local bleeding in injectable procedures (see hypertension and bruising in HOF).
• Pain and anxiety: they raise pressure and can mask the underlying picture.
• Anesthetic with a vasoconstrictor: in patients with cardiovascular disease, it deserves a specific assessment (see heart disease and anesthetics with vasoconstrictor).
• General safety: very high pressure with symptoms is a clinical emergency, regardless of the procedure.

How do you measure in a useful way?

Measurement only helps if it is done well. A few precautions:

A single measurement in an anxious patient can overestimate their usual pressure. That is why it is useful to repeat it after a few minutes of rest and compare it with the history the patient reports. A very high reading should never be dismissed without assessment, even when it is attributed to anxiety.

When does high pressure become a crisis?

In practical terms, what defines severity is the combination of a very high value with symptoms or signs of target-organ damage. Cutoff values and classification depend on the guideline the health service follows, so we do not set them here. What matters to the practice is recognizing the warning signs.

Warning symptoms include sudden severe headache, chest pain or tightness, shortness of breath, visual changes, confusion, altered speech, weakness or tingling on one side of the body, fainting, intense nausea and a nosebleed that will not stop.

What should you do at the moment?

Avoid offering medication on your own. If the patient has a prescribed antihypertensive and missed a dose, its use follows their physician's guidance, not a decision by the practice. If the pressure drops and the patient becomes asymptomatic, it is still most prudent to reschedule and recommend an assessment.

How do you tell it apart from other conditions?

High pressure with symptoms can be confused with other emergencies, and it is worth remembering the differential:

• Panic attack: can raise pressure, and the symptoms look alike. Do not presume panic without excluding warning signs.
• Chest pain: requires its own management and immediate activation of emergency services.
• Suspected stroke: altered speech, sudden facial asymmetry or weakness on one side require immediate emergency care.
• Anaphylaxis: can cause a drop in blood pressure, not a rise, but it causes confusion.
• Severe pain during injection: can raise pressure and can also signal a local complication (see severe pain during injection: a warning sign).

The team does not need to reach a diagnosis: it needs to recognize the signs, stabilize and call.

What should you ask in the medical history?

In the HOF medical history, ask directly:

• Does the patient have a diagnosis of hypertension? Are they in treatment? Do they take their medication every day?
• Have they ever had very high pressure, chest pain, stroke or heart attack?
• What is the last reading they know of? Do they measure at home?
• Do they use medications that affect pressure or bleeding? (see anticoagulants and injectable procedures).
• Do they have symptoms today, such as severe headache, dizziness or blurred vision?

Patients with cardiovascular disease deserve an assessment by the treating physician before a more extensive plan. Record what was discussed in the patient record and in the consent form.

How do you talk to the patient?

The patient may feel frustrated that the procedure is postponed, or frightened to learn their pressure is high. Communication should be clear and welcoming, without alarmism and without minimizing. See communicating risk to the patient and saying no to a patient with a contraindication.

How do you prepare the team?

Include elevated pressure in the exercises of the team emergency drill, check that the blood pressure monitor is calibrated and the cuff is the right size, and keep the HOF practice emergency kit checked. Write down the phone numbers for SAMU and the referral service, and train who makes the call and who gives the address.

Harmy takes no part in the emergency response. In routine care, it supports the planning conversation with an illustrative projection made from a frontal photo, always as a simulation and never as a promise of results.