Hypertensive urgencyMANAGEMENT

ENDOCRINE AND METABOLIC PRESENTATIONS · 12 SECTIONS

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517 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

Acute Porphyria Adrenal crisis Adrenal Insufficiency (Addisonian Crisis)Dehydration Diabetes Insipidus Diabetic Ketoacidosis (DKA)Euglycemic DKA (SGLT2 inhibitor)Galactosemia GLP-1 receptor agonist complications (retained gastric contents, aspiration risk)Homocystinuria Hypercalcemia Hyperkalemia Hypermagnesemia Hypernatremia Hyperosmolar Hyperglycemic State (HHS)Hypertensive emergency Hypertensive urgency Hypocalcemia Hypoglycemia Hypogonadism (Acute Presentation)Hypokalemia Hypomagnesemia Hyponatremia Hypoparathyroidism (Tetany)Insulin pump failure Maple Syrup Urine Disease (Crisis)Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCAD)Metabolic Acidosis Metabolic Alkalosis Myasthenia gravis crisis Myxedema coma Pellagra Pheochromocytoma (Crisis)Pituitary Apoplexy Pompe Disease (GSD II)Respiratory Acidosis Respiratory Alkalosis Scurvy SIADH Starvation Ketosis Tarui Disease (GSD VII)Thyroid storm Tyrosinemia Vitamin D Deficiency (Severe-Rickets)Von Gierke Disease (GSD I)

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp59

Triage and immediate threats

›Initial risk sort

›Severe BP threshold

›Systolic blood pressure 180 mmHg or higher

›Diastolic blood pressure 120 mmHg or higher

›Hypertensive urgency definition

›Severe BP elevation

›No acute target organ injury

›Hypertensive emergency definition

›Severe BP elevation

›Acute target organ injury

›Immediate escalation triggers

›New focal neurologic deficit

›Chest pain concerning for ACS or dissection

›Acute dyspnea with hypoxemia

›Pulmonary edema

›Altered mental status

›Seizure

›Visual loss

›Oliguria or anuria

›Pregnancy with severe BP

›Measurement confirmation

›Technique checks

›Correct cuff size

›Seated rest 5 minutes

›Arm at heart level

›No talking during reading

›Repeat and validate

02History/hx60

Symptom screen for target organ injury

›Red flag symptoms

›Neurologic

›Focal weakness or numbness

›Dysarthria or aphasia

›Severe headache

›Visual change

›Confusion

›Seizure

›Cardiopulmonary

›Chest pain

›Back pain tearing quality

›Dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Palpitations

›Renal

›Decreased urine output

›Hematuria

›Obstetric

›Pregnancy

›RUQ or epigastric pain

›New edema with headache or visual symptoms

Medication and exposure review

›Antihypertensive regimen

›Current medications and doses

›Last dose timing

›Recent changes

03Physical Exam/exam53

Vitals and global assessment

›Initial assessment

›Repeat BP after rest

›Orthostatic symptoms if large change

›Heart rate and rhythm

›Tachycardia suggesting stimulant or pain

›Respiratory status

›Work of breathing

›Oxygen saturation

›Temperature

›Fever suggesting infection or withdrawal syndromes

Target organ focused exam

›Neurologic

›Mental status

›Orientation and attention

›Cranial nerves

›Visual fields

›Pupillary responses

›Motor and sensory

›Focal deficit

›Cerebellar

›Ataxia

›Cardiovascular

›Perfusion

›Cool extremities

›Capillary refill

›Pulse symmetry

›Radial pulse discrepancy

04Differential Diagnosis/ddx46

Hypertensive crisis categories

›Primary diagnosis set

›Hypertensive urgency (ICD-10 I16.0)

›Severe BP elevation

›No acute target organ injury

›Hypertensive emergency (ICD-10 I16.1)

›Acute target organ injury

›Time critical management

›Unspecified hypertensive crisis (ICD-10 I16.9)

›Limited data or uncertain injury

Mimics and associated emergencies to exclude

›Neurologic

›Ischemic stroke (ICD-10 I63.x)

›Focal deficits

›Intracerebral hemorrhage (ICD-10 I61.x)

›Severe headache vomiting reduced consciousness

›Hypertensive encephalopathy

›Headache confusion seizures

›Cardiovascular

›Acute coronary syndrome (ICD-10 I21.x)

›Chest pain ECG ischemia troponin rise

›Acute aortic syndrome (ICD-10 I71.0x)

›Tearing chest or back pain pulse deficit

›Acute heart failure with pulmonary edema (ICD-10 I50.x)

›Dyspnea rales hypoxemia

›Renal

›Acute kidney injury (ICD-10 N17.x)

›Rising creatinine oliguria

05Laboratory Tests/lt30

Core labs when risk or uncertainty

›Screening set

›Serum creatinine and electrolytes

›AKI signal

›Potassium for diuretic or RAAS therapy safety

›Urinalysis

›Hematuria and proteinuria

›Casts suggesting renal parenchymal disease

›Pregnancy test when applicable

›Any patient with pregnancy potential

›Cardiac labs when symptoms or ECG concern

›High sensitivity troponin

›Chest pain or ischemic ECG

›Demand ischemia in severe hypertension context

›Hemolysis and pregnancy related when indicated

›Complete blood count

›Thrombocytopenia in HELLP concern

›AST ALT

›Hepatic injury in preeclampsia concern

›LDH

›Hemolysis support in HELLP concern

›Toxicology when suggested

›Urine drug screen

›Sympathomimetic exposure suspected

Interpretation and pitfalls

›Lab limitations

›Normal creatinine does not exclude acute BP mediated injury

›Baseline unknown

06Diagnostic Tests/dt52

Scoring Systems

›Classification and decision support

›Hypertensive crisis classification

›Urgency

›Severe BP

›No acute target organ injury

›Emergency

›Acute target organ injury present

›BP staging framework

›Chronic hypertension stage context

›Chronic control plan rather than acute lowering

›Funduscopic grading support

›Papilledema

›Emergency level concern

›Hemorrhages exudates

›End organ involvement consideration

MRI

›MRI indications

›Brain MRI

›Suspected posterior reversible encephalopathy syndrome

›Persistent neurologic symptoms with nondiagnostic CT

›Contraindications and logistics

›Unstable patient

›Implanted device limitations

›MRI interpretation pearls

›PRES patterns

›Posterior vasogenic edema distribution

›Stroke patterns

07Disposition/dispo30

Site of care decisions

›Admission and monitoring criteria

›Hypertensive emergency features

›ICU or stepdown depending on organ injury

›Urgency with high risk features

›Poor follow-up reliability

›New renal dysfunction

›Suspected secondary cause requiring inpatient workup

›Persistent severe BP with symptoms despite oral therapy

›Discharge criteria for urgency

›No evidence of acute target organ injury

›Symptom screen negative

›Exam reassuring

›Targeted tests reassuring when obtained

›Oral regimen plan in place

›Restart home meds if lapsed

›New prescription if needed

›Follow-up arranged

›24 to 72 hours for very high BP or comorbidity

›Within 7 days for lower risk

Follow-up timing and documentation

›Outpatient plan essentials

›Home BP monitoring plan

›Validated cuff recommendation

›Primary care appointment

›Confirmed date and location when possible

›Medication reconciliation

›Clear list and dosing schedule

08Treatment/t75

General principles

›Strategy for urgency

›No IV antihypertensives in urgency

›Unpredictable drops and hypoperfusion risk

›Oral therapy options

›Restart home regimen if nonadherence

›Add long acting agent if untreated or undertreated

›Avoid short acting nifedipine immediate release

›Excessive hypotension and ischemia risk

›Address reversible contributors

›Pain control

›Anxiety

›Withdrawal syndromes

›Stimulant cessation counseling

Oral antihypertensive options

›First line chronic classes for initiation or optimization

›ACE inhibitor

›Lisinopril PO

›10 mg once daily typical start

›Lower start in older adult or CKD risk

›Avoid in pregnancy

›Creatinine and potassium check within 1 to 2 weeks

›Enalapril PO

›5 mg once daily typical start

›Avoid in pregnancy

›ARB

›Losartan PO

›50 mg once daily typical start

09Special Populations/sp47

Pregnancy

›Pregnancy hypertensive crisis rules

›Severe BP in pregnancy

›Treat as emergency until proven otherwise

›Preeclampsia features

›Headache

›Visual symptoms

›RUQ or epigastric pain

›Proteinuria or renal dysfunction

›Medication safety

›Avoid ACE inhibitors and ARBs

›Fetotoxic risk

›Preferred acute agents for severe BP

›Labetalol

›IV pathway if severe features

›Nifedipine extended release

›Oral option when appropriate setting and monitoring

›Hydralazine

›IV pathway alternative

›Disposition

›Obstetrics consultation triggers

›Any severe BP with pregnancy

›Any preeclampsia symptom

Geriatric

›Older adult considerations

›Orthostatic risk

›Falls and syncope surveillance

›Wide pulse pressure

10Background/b30

Epidemiology

›Frequency and context

›Severe asymptomatic BP common in ED and urgent care

›Often chronic uncontrolled hypertension

›True hypertensive urgency less common than elevated BP without crisis

›Many cases driven by pain anxiety missed meds

Pathophysiology

›Perfusion and autoregulation

›Chronic hypertension shifts autoregulation rightward

›Higher baseline cerebral perfusion pressure

›Rapid BP lowering risk

›Cerebral hypoperfusion

›Myocardial ischemia

›AKI from reduced renal perfusion

›Emergency injury mechanisms

›Endothelial dysfunction

›Increased vascular permeability

›Fibrinoid necrosis and microangiopathy

›Encephalopathy

›Renal injury

Therapeutic Considerations

›Why urgency is outpatient focused

›Lack of proven short term benefit from rapid ED lowering in asymptomatic patients

›Harm potential from hypotension

›Long term risk reduction depends on sustained control

›Medication adherence

›Lifestyle changes

›Primary care continuity

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Very high blood pressure today without signs of organ damage

›Medication plan

›Take prescribed BP medicines exactly as directed

›Do not stop clonidine or beta blockers suddenly if you take them

›Home BP monitoring

›Check BP twice daily for 3 to 7 days

›Sit quietly 5 minutes before checking

›Record readings and bring to follow-up

›Follow-up timing

›Appointment within 1 to 7 days

›Earlier follow-up if BP remains 180 mmHg or higher systolic or 120 mmHg or higher diastolic

›Return now or call emergency services for

›Chest pain

›Severe shortness of breath

›Fainting

›New weakness numbness trouble speaking

›New severe headache

›Vision loss

›Confusion or seizure

›Decreased urine output

›Pregnancy with headache vision changes RUQ pain or swelling

12References/r12

Clinical guidelines and key sources

›Guideline set

›ACEP Clinical Policy

›Asymptomatic hypertension in the ED

›Routine ED intervention not required (ACEP Level C)

›Outpatient follow-up referral recommended (ACEP Level C)

›ACC AHA hypertension guideline framework

›Hypertensive crisis terminology and outpatient management principles

›Pregnancy hypertension guidance

›Severe BP in pregnancy treated as emergency until excluded

›Chronic hypertension management guidance

›First line classes

›Monitoring of kidney function and potassium after RAAS initiation

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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