Blood Pressure Management

No patient weight set. Open Pediatric Weight, Age, Height, or Length Tape to enable dose calculations.

Definitions — HTN vs urgency vs emergency

Stage 1 hypertension: SBP 130–139 OR DBP 80–89. Stage 2 hypertension: SBP ≥ 140 OR DBP ≥ 90. Hypertensive urgency: SBP > 180 and/or DBP > 120 WITHOUT acute end-organ damage. • No labs/imaging required beyond screening; treat with ORAL agents over 24–48 h. • Do NOT acutely lower BP in the ED — risk of hypoperfusion (stroke, MI, AKI). • Reinstitute or up-titrate home meds; arrange close follow-up. Hypertensive emergency: SBP > 180 and/or DBP > 120 WITH acute end-organ damage. • Brain: encephalopathy, ischemic stroke, ICH, SAH, PRES. • Heart: ACS, acute pulmonary edema (SCAPE), aortic dissection. • Kidney: AKI, microangiopathic hemolysis. • Pregnancy: severe preeclampsia / eclampsia. • Treat with IV titratable agents — admit to monitored bed / ICU. General targets: ↓ MAP 10–20% in first hour, then 5–15% over next 23 h. Avoid > 25% drop in 1st hour. Scenario-specific targets override (see tables below).

First-line IV agents — adult emergency dosing

Drug	Dose	Notes / cautions
	10–20 mg IV q10 min, double up to 80 mg (max 300 mg). Gtt 0.5–2 mg/min	α + β-blocker. AVOID if HR < 60, severe asthma, decompensated HF, 2°/3° AVB
	Start 5 mg/hr IV, ↑ 2.5 mg/hr q5–15 min, max 15 mg/hr	DHP CCB; smooth titration. Preferred in stroke, ICH, eclampsia. Reflex tachy possible
	Start 1–2 mg/hr, double q90 sec, max 16–32 mg/hr	Ultra-short-acting CCB. Caution: lipid emulsion (egg/soy allergy, hypertriglyceridemia)
	Load 500 mcg/kg over 1 min → gtt 50–300 mcg/kg/min	Cardioselective β1; ideal for aortic dissection (with vasodilator), perioperative HTN
Nitroglycerin	5–200 mcg/min IV (start 5–10, ↑ q3–5 min)	Preload reducer. First-line in APE/SCAPE, ACS. Avoid SBP < 100, RV infarct, PDE-5 use
Nitroprusside	0.25–10 mcg/kg/min IV (start low)	Mixed art/venous. Cyanide / thiocyanate toxicity risk > 24 h or in renal failure. Light-protect
	10–20 mg IV q20–30 min PRN	Unpredictable; reflex tachy. Useful in eclampsia / pregnancy
	0.625–1.25 mg IV q6h	ACE-i; avoid in pregnancy, bilateral RAS, AKI
	5–15 mg IV q5–15 min	α-blocker. First-line for catecholamine excess (pheo, , crisis, clonidine withdrawal)

High BP + LOW HR (relative bradycardia)

Avoid β-blockers (, ) and non-DHP CCBs (, ) — they will worsen bradycardia / AV block. Preferred agents: • IV — DHP CCB, no AV nodal effect; smooth titration. • IV — ultra-short DHP CCB, similar profile to . • IV — direct arterial vasodilator; can actually raise HR (reflex), useful when bradycardic. • Nitroglycerin / Nitroprusside — vasodilators, neutral-to-↑ HR. Watch for: Cushing reflex (HTN + bradycardia + irregular respirations) → suggests ↑ ICP — DO NOT lower BP aggressively; treat ICP first (HOB 30°, mannitol/3% NaCl, neurosurgery).

Scenario · Ischemic stroke (no tPA)

First-line	Adult dose	Caution / max
Permissive HTN	Treat ONLY if SBP > 220 or DBP > 120; ↓ MAP ≤ 15% in 1st hr	Aggressive lowering worsens penumbra
IV	10–20 mg q10 min, double to 80 mg (max 300 mg)	Avoid HR < 60, asthma, AVB
IV gtt	5 mg/hr → ↑ 2.5 mg/hr q5–15 min, max 15 mg/hr	Preferred if HR-limited
AVOID	Nitroprusside, sublingual nifedipine	↑ ICP, uncontrolled drop

Scenario · Ischemic stroke (tPA candidate)

First-line	Adult dose	Caution / max
Target	BP < 185/110 PRE-, < 180/105 × 24 h post	Hold if cannot achieve
IV	10–20 mg q10 min × 2, then gtt 2–8 mg/min	Max bolus total 300 mg
IV gtt	5 mg/hr → titrate q5 min to target	Max 15 mg/hr
AVOID	Sublingual nifedipine,	Unpredictable / overshoots

Scenario · Aortic dissection

First-line	Adult dose	Caution / max
FIRST	Load 500 mcg/kg over 1 min → gtt 50–300 mcg/kg/min	Target HR < 60 BEFORE vasodilator
Then gtt	5 mg/hr → titrate to SBP 100–120, max 15 mg/hr	Add only after HR controlled
Or Nitroprusside	0.25–10 mcg/kg/min IV	Cyanide risk > 24 h / renal failure
Pain control	25–100 mcg IV q5–10 min	Reduces sympathetic drive
AVOID	Vasodilator before β-block	Reflex tachy → ↑ shear stress → propagation

Scenario · Acute pulmonary edema / SCAPE

First-line	Adult dose	Caution / max
Nitroglycerin IV	Start 50–100 mcg/min, double q3–5 min; high-dose 200–400 mcg/min OK	Avoid SBP < 100, RV infarct, PDE-5 use
BiPAP	IPAP 10–15 / EPAP 5–8	First-line ventilation
Furosemide IV	40–80 mg (or 2× home dose)	Adjunct; not first-line in SCAPE
gtt	1–2 mg/hr → max 16–32 mg/hr	Alternative if insufficient
AVOID	β-blockers (, )	Negative inotrope in acute HF

Scenario · Acute coronary syndrome

First-line	Adult dose	Caution / max
Nitroglycerin IV	5–200 mcg/min IV	Avoid SBP < 100, RV infarct, PDE-5
gtt	Load 500 mcg/kg → 50–300 mcg/kg/min	If no contraindication
Metoprolol IV	5 mg IV q5 min × 3	Avoid in HF, HR < 60, hypotension
AVOID		Reflex tachy → ↑ myocardial demand

Scenario · Sympathetic crisis (cocaine, MAOI, clonidine w/d)

First-line	Adult dose	Caution / max
	2 mg IV q5–10 min OR 5–10 mg IV	First-line — treat agitation + HTN
IV	5 mg IV q5–15 min PRN	α-blocker; max 15 mg/dose
gtt	5 mg/hr, max 15 mg/hr	2nd-line vasodilator
AVOID	β-blocker monotherapy (incl. controversial)	Unopposed α → worse HTN, coronary spasm

Scenario · Eclampsia / severe preeclampsia

First-line	Adult dose	Caution / max
	4–6 g IV load over 20 min → 1–2 g/hr gtt	Watch DTRs / RR; at bedside
IV	20 mg → 40 mg → 80 mg q10 min (max 300 mg)	First-line BP agent in pregnancy
IV	5–10 mg q20 min PRN	Alternative; reflex tachy
gtt	5 mg/hr → max 15 mg/hr	If refractory
AVOID	ACE-i, ARB,	Fetal toxicity / cyanide

Scenario · Pheochromocytoma

First-line	Adult dose	Caution / max
IV	5 mg IV q5–15 min PRN	α-blockade FIRST
gtt	5 mg/hr → max 15 mg/hr	Adjunct vasodilator
β-blocker (after α)	50–300 mcg/kg/min OR metoprolol 5 mg IV	ONLY after adequate α-block
AVOID	β-blocker monotherapy	Unopposed α → hypertensive crisis

Brain bleed — overview & shared principles

Goal: control BP without dropping cerebral perfusion or raising ICP. • Use IV titratable agents with NO direct ICP effect (DHP CCBs). • Establish arterial line within 30 min for beat-to-beat BP. • HOB 30°, midline neck, normothermia, normoglycemia, normocapnia (PaCO₂ 35–40). • If Cushing reflex (HTN + bradycardia + irregular resp) → treat ICP FIRST (3% NaCl 250 mL or mannitol 1 g/kg, hyperventilate to PaCO₂ 30–35 as bridge, neurosurgery STAT). DO NOT aggressively lower BP — preserves CPP. • CPP target ≥ 60–70 mmHg (CPP = MAP − ICP).

ICH (intracerebral hemorrhage) — exact dosing

Step	Drug & titration	Target / max
Target	SBP 140 (range 140–160) per AHA / INTERACT-2 / ATACH-2	Achieve within 1 h; maintain × 24 h
1st-line	IV gtt — start 5 mg/hr → ↑ 2.5 mg/hr q5–15 min	Max 15 mg/hr; wean once at goal
1st-line alt	IV gtt — start 1–2 mg/hr, double q90 sec	Max 16–32 mg/hr; lipid load limits
2nd-line bolus	10–20 mg IV q10 min (double to 80 mg)	Max cumulative 300 mg; HOLD if HR < 60
2nd-line gtt	load 500 mcg/kg → 50–300 mcg/kg/min	Use if HR-driven or β-block needed
Reversal	If on warfarin: 25–50 U/kg + Vit K 10 mg IV. DOAC: (Xa) or (dabigatran)	Within 60 min of presentation
AVOID	Nitroprusside (↑ ICP, cerebral steal, cyanide)	—
AVOID	(unpredictable, prolonged, reflex tachy)	—
AVOID	Sublingual nifedipine (uncontrolled drop)	—

SAH (subarachnoid hemorrhage) — exact dosing

Step	Drug & titration	Target / max
Target (unsecured aneurysm)	SBP < 160 (some centers < 140)	Until aneurysm secured (coil/clip)
Target (secured)	Permissive HTN — induced HTN if vasospasm (SBP up to 180–220)	Maintain euvolemia
1st-line	IV gtt — start 5 mg/hr → ↑ 2.5 mg/hr q5–15 min	Max 15 mg/hr
1st-line alt	IV gtt — 1–2 mg/hr, double q90 sec	Max 16–32 mg/hr
Vasospasm prophylaxis	Nimodipine 60 mg PO/NG q4h × 21 d (start within 96 h)	↓ to 30 mg q2h if hypotension
Pain / sedation	25–50 mcg IV q1h + acetaminophen 1 g IV q6h	Lower sympathetic drive
2nd-line	10–20 mg IV q10 min (max 300 mg)	Avoid
AVOID	Nitroprusside (↑ ICP, steal, cyanide)	—
AVOID	(unpredictable, masks neuro exam)	—
AVOID	Aggressive overshoot — ↓ CPP risks delayed cerebral ischemia	—

Brain bleed · titration & monitoring rules

• Arterial line within 30 min — cuff BP under-reads in low CO. • Reassess BP + neuro exam q5 min during titration, q15 min once at goal. • Pause titration if MAP drops > 20% from baseline OR new neuro deficit — bolus 250 mL NS, recheck CT. • Treat pain (), nausea (), bladder distension, hypoxia — all elevate BP. • Reverse anticoagulation in parallel (do not wait for BP control). • Glucose 140–180; temp < 37.5; Na 140–145 (avoid hyponatremia → cerebral edema).

Oral agents — hypertensive urgency (no end-organ damage)

Drug	Dose	Notes
PO	200–400 mg PO, may repeat q2–3 h	Onset 1–2 h; same cautions as IV
Captopril SL/PO	12.5–25 mg PO, repeat q1–2 h	Onset 15–30 min; avoid pregnancy / AKI / bilat RAS
Clonidine PO	0.1–0.2 mg PO, then 0.1 mg q1h (max 0.7 mg)	Sedation; rebound HTN if stopped
Amlodipine PO	5–10 mg PO daily	Slow onset; for outpatient titration
PO	10–25 mg PO q6–8 h	Reflex tachy; avoid as monotherapy