Hypertensive Emergency

Urgency vs Emergency

Urgency: SBP > 180 / DBP > 120 without end-organ damage → oral agents over 24–48 h, do not acutely lower in ED. Emergency: same BP with end-organ damage (brain, heart, kidney, eclampsia, dissection) → IV titratable agents.

Recognition
  • Vitals both arms, fundoscopy (papilledema, hemorrhages), neuro exam
  • ECG + troponin — ACS, LVH, strain
  • CXR — pulmonary edema, widened mediastinum
  • BMP, UA — Cr, hematuria, proteinuria
  • CBC ± smear — microangiopathic hemolysis (schistocytes)
  • CT head if neuro symptoms (ICH, ischemic stroke, PRES)
  • CTA chest/abd if tearing pain, pulse deficit, BP differential → dissection
  • β-hCG + UA for protein in any female of childbearing age
  • Consider: TSH, urine metanephrines (pheo), urine tox (cocaine, sympathomimetics)
Management
General target (no scenario override)
  • ↓ MAP 10–20% in first hour
  • Then ↓ 5–15% over next 23 h
  • Avoid > 25% drop in first hour — risk stroke / MI / AKI
Step-by-step by scenario (target → first-line IV)
  • Aortic dissection
    Target: SBP 100–120 AND HR < 60 within 20 min
    Agent: 500 mcg/kg load → 50–300 mcg/kg/min FIRST, then 5 mg/hr or 0.25 mcg/kg/min
  • Acute pulmonary edema (SCAPE)
    Target: ↓ SBP 20–30% rapidly
    Agent: Nitroglycerin 5–10 mcg/min → titrate q3–5 min to 200 mcg/min (high-dose bolus 0.4–2 mg often used) + BiPAP + loop diuretic
  • ACS / NSTEMI / STEMI
    Target: SBP < 140; pain-free
    Agent: Nitroglycerin gtt + or (avoid in inferior MI / RV infarct, )
  • Ischemic stroke (no tPA)
    Target: Treat only if SBP > 220 or DBP > 120 → ↓ 15% in 24 h
    Agent: 10–20 mg IV q10 min or 5 mg/hr titrate
  • Ischemic stroke + tPA candidate
    Target: SBP < 185 / DBP < 110 before lysis; SBP < 180 ×24 h after
    Agent: 10–20 mg IV ×1–2 or 5 mg/hr
  • ICH / hemorrhagic stroke
    Target: SBP 140 within 1 h (if 150–220); SBP 140–160 if > 220
    Agent: 5 mg/hr → max 15 OR 1–2 mg/hr; bolus
  • SAH
    Target: SBP < 160 until aneurysm secured
    Agent: or drip; bolus
  • Severe preeclampsia / eclampsia
    Target: SBP < 160 / DBP < 110
    Agent: 20 mg IV (then 40, 80) OR 5–10 mg IV q20 min OR nifedipine 10 mg PO + Mag sulfate 4–6 g IV load → 1–2 g/hr
  • Catecholamine excess (pheo, cocaine, MAOI, clonidine withdrawal)
    Target: ↓ MAP 10–20% / 1 h
    Agent: 5–15 mg IV q5–15 min (α first!) ± ; AVOID β-blocker monotherapy (unopposed α)
  • Acute kidney injury / scleroderma renal crisis
    Target: ↓ MAP 10–20% / 1 h; avoid hypoperfusion
    Agent: or ; AVOID (cyanide/thiocyanate in renal failure)
  • Hypertensive encephalopathy / PRES
    Target: ↓ MAP 20–25% / 1 h
    Agent: or drip
  • Hypertensive + bradycardic
    Target: Treat underlying cause first; ↓ MAP 10–20% / 1 h if ICP excluded
    Agent: First-line IV: or drip (DHP CCB — no HR effect). IV 10–20 mg also safe (direct vasodilator, causes mild reflex ↑HR — beneficial here). PO/adjunct options if not crashing: amlodipine 5–10 mg PO (DHP CCB, HR-neutral). Clonidine — use with CAUTION (central sympatholytic can further ↓HR; avoid if HR <50 or high-grade AV block). AVOID β-blockers (, , metoprolol) and non-DHP CCBs (, ). If Cushing reflex (↑ICP): treat ICP first, do NOT lower BP aggressively
First-line IV agents — quick reference
  • 5 mg/hr IV, ↑ 2.5 mg/hr q5–15 min (max 15 mg/hr)
  • 1–2 mg/hr IV, double q90 sec (max 16–32 mg/hr)
  • 10–20 mg IV q10 min, double up to 80 mg (max 300 mg); gtt 0.5–2 mg/min
  • 500 mcg/kg load → 50–300 mcg/kg/min
  • Nitroglycerin 5–200 mcg/min IV (start 5–10)
  • Nitroprusside 0.25–10 mcg/kg/min IV (light-protect)
  • 10–20 mg IV q20–30 min PRN
  • 5–15 mg IV q5–15 min
  • 0.625–1.25 mg IV q6h
Pearls / pitfalls
  • HR < 60 / AV block / decompensated HF / asthma: avoid β-blockers + non-DHP CCBs
  • Cushing reflex (↑ICP): HTN + bradycardia → treat ICP first, do NOT lower BP aggressively
  • Pregnancy: avoid ACEi/ARB, nitroprusside (cyanide → fetus), enalaprilat
  • Renal failure / > 24 h infusion: avoid nitroprusside (cyanide/thiocyanate)
  • Cocaine / sympathomimetic: benzos first; avoid β-blocker monotherapy
  • Sublingual nifedipine: never — uncontrolled BP drops, stroke/MI

Educational aid only — verify against local protocol & current AHA / ACC / ACEP guidelines.