Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Confirm true emergency with organ injury; set target reduction (usually 20–25% MAP in 1 h).
- Choose agent(s) based on syndrome (dissection needs rapid HR/BP control; pregnancy uses labetalol/hydralazine).
- Admit to ICU; address precipitant; transition to oral regimen once stable.
Clinical Synopsis & Reasoning
BP with acute target‑organ injury (encephalopathy, ACS, APE, aortic dissection, AKI). Reduce MAP by ~20–25% in the first hour (except aortic dissection/ischemic stroke with unique targets) using IV agents (nicardipine, clevidipine, labetalol). Identify/ treat precipitating cause and avoid rapid overcorrection.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Neuro exam, ECG/troponin, BMP/UA, CXR | Target‑organ evaluation | Identify end‑organ involvement | — |
| CT head (neurologic symptoms) and CTA chest (tearing pain) | Rule out ICH/dissection | Imaging‑driven targets | — |
| Urine tox/medication review | Etiology | Sympathomimetics, MAOIs, nonadherence | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Acute target-organ damage (encephalopathy, ACS, APE, aortic dissection) | End-organ injury | ICU; IV titratable agents; specific targets |
| Pregnancy (severe preeclampsia/eclampsia) | Maternal/fetal risk | Obstetric pathway; Mg; labetalol/hydralazine |
| Stroke (ischemic/ICH) | BP nuance | Follow stroke-specific targets |
| Renal failure or pheochromocytoma crisis | Special therapy | Nicardipine/clevidipine; α-blockade then β |
| Medication nonadherence or stimulant use | Precipitant | Counsel and treat tox |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Nicardipine or Clevidipine infusion | Arterial vasodilators | Minutes | Preferred in neuro/renal syndromes | Titrate with arterial line |
| Labetalol bolus/infusion | α/β‑blocker | Minutes | Useful in many scenarios | Avoid in asthma/CHF decompensation |
| Nitroprusside/Nitroglycerin (selected) | Vasodilators | Minutes | For APE/HTN emergencies with ischemia | Cyanide risk (nitroprusside) |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AHA scientific statement on hypertensive emergencies — Link