›Immediate stabilization
›Monitor
›IV access
›Repeat BP with correct cuff
›Triggered rapid pathways
›ECG within 10 minutes for chest pain or dyspnea
›CT head pathway for neuro deficit
›Immediate consult triggers
›Stroke team for suspected acute stroke
›Cardiology for ACS and pulmonary edema
›Vascular surgery for aortic syndrome concern
›Obstetrics for pregnancy severe BP
BP targets and rate of reduction
›General hypertensive emergency target
›MAP reduction 20 percent to 25 percent in first hour
›Avoid rapid normalization
›Aortic dissection target
›HR target less than 60
›SBP target less than 120
›Acute ischemic stroke not thrombolysis candidate
›Permissive hypertension
›Treat if BP greater than 220 over 120
›Thrombolysis eligible stroke
›BP target less than 185 over 110 before thrombolysis
›BP target less than 180 over 105 after thrombolysis
›Intracerebral hemorrhage
›SBP target 140 to 160 local protocol dependent
›Avoid hypotension
›Pregnancy severe range BP
›Treat if BP 160 over 110 or higher
›Seizure prophylaxis pathway if indicated
IV antihypertensives dosing examples
›Nicardipine infusion
›Start 5 mg per hour
›Titrate 2.5 mg per hour every 5 to 15 minutes
›Maximum 15 mg per hour
›Clevidipine infusion
›Start 1 mg per hour to 2 mg per hour
›Double every 90 seconds to 3 minutes until near goal
›Maximum 21 mg per hour local protocol dependent
›Labetalol IV bolus
›20 mg IV over 2 minutes
›Repeat 20 mg to 80 mg every 10 minutes as needed
›Maximum 300 mg
›Labetalol infusion
›0.5 mg per minute to 2 mg per minute
›Titration local protocol dependent
›Esmolol infusion
›Load 500 mcg per kg over 1 minute
›Start 50 mcg per kg per minute
›Titrate by 50 mcg per kg per minute every 5 minutes
›Nitroglycerin infusion
›Start 5 mcg per minute
›Increase by 5 mcg per minute every 3 to 5 minutes
›Typical range 5 mcg per minute to 200 mcg per minute
›Nitroprusside infusion
›Start 0.3 mcg per kg per minute
›Titrate to effect
›Cyanide and thiocyanate toxicity risk
Special situation medication choices
›Pulmonary edema phenotype
›Nitroglycerin preferred
›Nicardipine alternative
›Aortic dissection phenotype
›Beta blockade first
›Add vasodilator after HR control
›Pregnancy severe range BP
›Labetalol IV
›Hydralazine IV
›Nifedipine PO immediate release local protocol dependent
›Sympathomimetic intoxication
›Benzodiazepines for agitation
›Vasodilator choice local protocol dependent
›Avoid rapid BP lowering in asymptomatic severe hypertension
›Ischemic stroke risk
›Myocardial ischemia risk
›Avoid ACE inhibitor and ARB in pregnancy
›Fetal renal injury risk
›Oligohydramnios risk
›Avoid nitroprusside in pregnancy when alternatives available
›Fetal toxicity concern
›Maternal toxicity concern
›Monitoring cadence
›Recheck BP every 5 to 15 minutes during titration
›Continuous pulse oximetry for respiratory symptoms
›Response assessment
›Symptom improvement
›Neuro status change
›Urine output trend