Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow β check first
Diagnostic flow β check first
- Confirm BP w/ correct cuff in both arms.
- Look for end-organ damage: chest/back pain, SOB, neuro deficit, vision change, headache, pregnancy β workup.
- Yes end-organ β emergency, IV titratable agent in monitored bed.
- No end-organ β urgency: restart outpatient meds, PCP f/u, do not crash BP.
Differential diagnosis β checklist
0/16
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
Hypertensive emergency (end-organ)0/7
Hypertensive urgency / asymptomatic0/4
Secondary causes0/5
Initial ED workup
Bedside0/4
- BP both arms with appropriately sized cuff; recheck after rest
- ECG for ischemia / LVH
- Neuro exam, fundoscopy if available
- POCUS lungs (B-lines), heart, aorta
Labs0/6
- BMP (Cr)
- Troponin if chest pain / SOB
- UA (protein, blood)
- CBC
- TSH if indicated
- Urine pregnancy in females of reproductive age
Imaging0/3
- CXR for pulmonary edema / mediastinum
- Non-contrast CT head if neuro symptoms
- CTA chest if dissection suspected
Initial management0/6
- Identify emergency vs urgency: end-organ damage = emergency.
- Emergency: lower MAP by β€ 25% over first hour with titratable IV agent (nicardipine, labetalol, esmolol, NTG).
- Dissection: esmolol/labetalol FIRST (rate before pressure), goal SBP 100β120.
- SCAPE: high-dose NTG + BiPAP.
- Pregnancy: labetalol 20 mg IV or hydralazine 5 mg IV; magnesium for seizure ppx.
- Asymptomatic urgency: oral therapy, PCP follow-up; NO IV/SL nifedipine.
Pearls / pitfalls
Pearls
- Don't treat the number β treat end-organ damage.
- Avoid sublingual nifedipine (uncontrolled drop, stroke risk).
- In dissection: control HR before BP.
- In suspected stroke: permissive HTN unless tPA candidate (then < 185/110).