›Treatment architecture
›Address reversible drivers
›Analgesia for severe pain
›Anxiolysis for severe anxiety
›Withdrawal management pathway
›Route selection
›IV titratable agents for emergency
›Oral agents for urgency
›Monitoring during BP lowering
›Neuro checks for CNS presentations
›Urine output tracking
›Frequent electrolytes for prolonged infusions
IV antihypertensive infusions
›Titrated vasodilator infusions
›Nicardipine IV infusion
›Initiate 5 mg/hour
›Titrate 2.5 mg/hour every 5-15 minutes
›Maximum 15 mg/hour
›Preferred phenotypes
›Neurologic emergencies
›General hypertensive emergency without tachycardia
›Precautions
›Reflex tachycardia risk
›Peripheral edema risk
›Clevidipine IV infusion
›Initiate 1-2 mg/hour
›Titrate by doubling every 90 seconds early as needed
›Typical range 4-16 mg/hour
›Advantages
›Rapid onset and offset
›Easy fine titration
›Contraindications
›Egg or soy allergy
›Disordered lipid metabolism
›Nitroprusside IV infusion
›Initiate 0.3 mcg/kg/min
›Titrate 0.5 mcg/kg/min every 5 minutes
›Maximum 10 mcg/kg/min
›Role limitations
›Cyanide or thiocyanate toxicity risk with prolonged use
›Avoid in renal failure when possible
›Avoid in pregnancy when possible
›Nitroglycerin IV infusion
›Initiate 5-10 mcg/min
›Titrate 5-10 mcg/min every 3-5 minutes
›Typical maximum 200 mcg/min
›Preferred phenotypes
›Acute coronary syndrome
›Acute pulmonary edema
›Limitations
›Less effective for isolated BP control
›Headache and tachyphylaxis
IV bolus antihypertensives
›Intermittent IV agents
›Labetalol IV bolus
›Initiate 10-20 mg IV over 2 minutes
›Repeat 20-80 mg every 10 minutes as needed
›Maximum 300 mg total
›Alternative labetalol infusion
›Initiate 0.5-2 mg/min
›Titrate to effect with close bradycardia monitoring
›Contraindications
›Asthma with active bronchospasm
›Severe bradycardia or high-grade AV block
›Cardiogenic shock
›Esmolol IV bolus and infusion
›Initiate 500 mcg/kg bolus over 1 minute
›Continue 50 mcg/kg/min infusion
›Titrate 25-50 mcg/kg/min every 5-10 minutes
›Preferred phenotypes
›Aortic dissection adjunct
›Perioperative sympathetic surge
›Precautions
›Bradycardia
›Decompensated heart failure
›Hydralazine IV
›Initiate 5-10 mg IV
›Repeat every 20-40 minutes as needed
›Unpredictable response
›Role limitations
›Avoid as first-line for most emergencies
›Reflex tachycardia risk
›Enalaprilat IV
›Initiate 0.625-1.25 mg IV
›Repeat every 6 hours as needed
›Maximum 5 mg per dose
›Preferred phenotype
›Heart failure with afterload excess when renal function acceptable
›Contraindications
›Pregnancy
›Bilateral renal artery stenosis suspicion
›Hyperkalemia
Condition-specific protocols
›Aortic dissection management
›Anti-impulse therapy sequence
›Initiate beta-blocker first
›Esmolol infusion pathway
›HR target less than 60 beats/min
›Add vasodilator after beta-blockade if needed
›Nicardipine infusion pathway
›SBP target less than 120 mmHg
›Guideline alignment
›Class I recommendation for rapid HR control and SBP lowering in acute aortic syndromes
›Acute pulmonary edema management
›Primary therapies
›Nitroglycerin infusion pathway
›Rapid titration for symptom relief
›Noninvasive ventilation when appropriate
›CPAP or BiPAP for work of breathing
›Adjuncts
›Loop diuretic if volume overloaded
›Monitor electrolytes mmol/L
›Acute coronary syndrome management
›BP control adjunct
›Nitroglycerin infusion pathway when ongoing pain or pulmonary edema
›Avoided therapies
›Nitroprusside in suspected coronary ischemia when alternatives available
›Hypertensive encephalopathy or PRES
›Preferred agents
›Nicardipine infusion pathway
›Gradual MAP reduction targets
›Clevidipine infusion pathway
›Tight titration with frequent neuro checks
›Avoided patterns
›Rapid overshoot hypotension
›Sympathomimetic toxicity
›First-line symptom control
›Benzodiazepines for agitation and autonomic surge
›Reduced catecholamine drive
›If persistent hypertension
›Phentolamine IV
›Initiate 1-5 mg IV
›Repeat every 5-15 minutes as needed
›Nicardipine infusion pathway
›Avoid beta-blocker monotherapy in acute cocaine toxicity
›Preeclampsia or eclampsia
›Antihypertensive options
›Labetalol bolus pathway
›SBP target less than 160 mmHg
›Hydralazine IV pathway
›Alternative if beta-blocker contraindicated
›Nicardipine infusion pathway
›ICU titration option when needed
›Seizure prophylaxis and treatment
›Magnesium sulfate
›Initiate 4-6 g IV loading dose
›Continue 1-2 g/hour infusion
›Guideline alignment
›Class I recommendation for magnesium sulfate in eclampsia prevention and treatment
Oral therapy for hypertensive urgency
›Nonemergent BP management
›Resume home antihypertensives when appropriate
›Missed doses without contraindication
›Oral options by context
›Amlodipine
›Typical onset hours
›ACE inhibitor or ARB per baseline plan
›Avoid in pregnancy
›Beta-blocker continuation when indicated
›Avoid abrupt withdrawal
›Avoided agents
›Immediate-release nifedipine for rapid lowering
›Ischemia risk from precipitous drop