The immediate priorities are pain relief, control of blood pressure, and volume resuscitation, followed by appropriate imaging. Pain relief will require intravenous opiates, sometimes in high doses. The blood pressure should be reduced to normal or below; a target systolic blood pressure of 100 mmHg is usual, but higher pressures may have to be accepted if organ perfusion and urine output are inadequate. A combination of vasodilators and b-blockers should be used, with the aim of reducing not only blood pressure but also shear stress by decreasing d P/dt. This requires close monitoring of circulatory adequacy. Sodium nitroprusside by continuous infusion offers the most flexible method of blood pressure control. Beta-blockade is most conveniently achieved with infusions of labetalol or esmolol.
Definitive imaging should be performed as soon as possible. Close monitoring, blood pressure control, and analgesia must be maintained throughout. An experienced clinician, appropriately equipped, should accompany the patient at all times.
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