Hypertensive urgencyMANAGEMENT

ENDOCRINE AND METABOLIC PRESENTATIONS · 12 SECTIONS

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517 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

Acute Porphyria Adrenal crisis Adrenal Insufficiency (Addisonian Crisis)Dehydration Diabetes Insipidus Diabetic Ketoacidosis (DKA)Galactosemia Homocystinuria Hypercalcemia Hyperkalemia Hypermagnesemia Hypernatremia Hyperosmolar Hyperglycemic State (HHS)Hypertensive emergency Hypertensive urgency Hypocalcemia Hypoglycemia Hypogonadism (Acute Presentation)Hypokalemia Hypomagnesemia Hyponatremia Hypoparathyroidism (Tetany)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 Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

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

›Repeat after rest if initial severe reading

›Manual measurement if automated questionable

›Both arms if large discrepancy concern

›Pseudohypertension considerations

›Marked arterial stiffness in older adult

›Very high cuff pressures with minimal symptoms

›Early decisions

›Emergency present

›IV therapy pathway

›ICU or monitored bed pathway

›Urgency likely

›Oral therapy or resume home regimen

›Outpatient follow-up plan

›White coat or pain anxiety contribution

›Recheck after analgesia or anxiolysis if appropriate

Hemodynamic targets and tempo

›BP reduction principles

›Avoid rapid BP lowering in urgency

›No immediate large drop targets

›Cerebral and coronary hypoperfusion risk

›Typical urgency target

›Gradual reduction over 24 to 48 hours

›When to avoid acute lowering

›Chronic severe hypertension with preserved perfusion

›Older adult with cerebrovascular disease history

Communication and coordination

›Team and follow-up activation

›Primary care linkage

›Appointment within 1 to 7 days based on risk

›Pharmacy and adherence supports

›Refill barriers

›Cost and access barriers

›Secondary cause pathway if suggested

›Targeted testing rather than broad panels

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

›Adherence pattern

›Missed doses last week

›Refill access

›Recent discontinuations

›Clonidine withdrawal

›Beta blocker withdrawal

›Substances that raise BP

›Sympathomimetics

›Cocaine

›Methamphetamine

›Decongestants

›Medications

›NSAIDs

›Oral contraceptives

›Glucocorticoids

›SNRIs

›Calcineurin inhibitors

›Alcohol

›Heavy use

›Withdrawal symptoms

Secondary hypertension clues

›Renal disease history

›CKD

›Polycystic kidney disease

›Endocrine patterns

›Episodic headache palpitations diaphoresis

›Weight gain striae proximal weakness

›Heat intolerance tremor

›Sleep and breathing

›Snoring

›Daytime somnolence

›Vascular clues

›Claudication

›Abdominal bruit history

›Sudden onset hypertension at young age

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

›Cardiac auscultation

›New murmur

›Volume status

›Jugular venous distension

›Peripheral edema

›Pulmonary

›Rales

›Pulmonary edema signs

›Wheeze

›Asthma or COPD context

›Fundoscopic

›Hypertensive retinopathy

›Hemorrhages

›Cotton wool spots

›Papilledema

›Abdomen

›Abdominal tenderness

›Pregnancy or hepatic capsule pain

›Bruits

›Renal artery stenosis clue

PITFALLS

›Common traps

›Symptom absence does not exclude emergency

›Silent renal injury possibility

›Single automated reading anchoring

›Repeat measurement and technique errors

›Treating the number without context

›Overcorrection hypoperfusion risk

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

›Pregnancy

›Preeclampsia with severe features (ICD-10 O14.1x)

›Headache visual symptoms RUQ pain

›Eclampsia (ICD-10 O15.x)

›Seizure

Secondary hypertension etiologies

›Renal and renovascular

›CKD progression

›Proteinuria history

›Renal artery stenosis

›Abdominal bruit flash pulmonary edema

›Endocrine

›Pheochromocytoma

›Episodic spells diaphoresis palpitations

›Primary hyperaldosteronism

›Hypokalemia metabolic alkalosis

›Thyrotoxicosis

›Tremor weight loss tachyarrhythmia

›Sleep related

›Obstructive sleep apnea

›Snoring daytime sleepiness

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

›Proteinuria chronic vs acute distinction

›Prior records helpful

›Troponin mild elevation

›Demand ischemia vs ACS differentiation with ECG and trend

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

›Diffusion restriction

›CT indications

›CT head without contrast

›Focal deficit

›Altered mental status

›Thunderclap headache

›CT angiography chest abdomen pelvis

›Aortic dissection features

›Pulse deficit

›Neurologic deficit with chest or back pain

›CT pitfalls

›Normal CT head early ischemic stroke

›MRI or clinical pathway if persistent deficit

›Contrast nephropathy concern

›Risk assessment with baseline kidney function

Ultrasound

›POCUS applications

›Lung ultrasound

›B lines supporting pulmonary edema

›Cardiac ultrasound

›LV function estimate

›Pericardial effusion

›Renal ultrasound

›Hydronephrosis in obstructive uropathy concern

›Ultrasound limitations

›Aortic dissection exclusion

›Negative POCUS does not exclude

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

›ACEP Clinical Policy note

›Asymptomatic markedly elevated BP

›Routine ED rapid lowering not recommended (ACEP Level C)

›Outpatient follow-up emphasized (ACEP Level C)

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

›Avoid in pregnancy

›Creatinine and potassium check within 1 to 2 weeks

›Calcium channel blocker dihydropyridine

›Amlodipine PO

›5 mg once daily typical start

›Edema monitoring

›Thiazide like diuretic

›Chlorthalidone PO

›12.5 mg once daily typical start

›Sodium and potassium check within 1 to 2 weeks

›Shorter onset options for selected urgency cases

›Captopril PO

›12.5 mg to 25 mg single dose

›Repeat in 1 to 2 hours if needed

›Max 50 mg in short window typical

›Avoid in pregnancy

›Caution bilateral renal artery stenosis

›Labetalol PO

›100 mg to 200 mg single dose

›Repeat in 2 to 3 hours if needed

›Total 400 mg to 600 mg over 24 hours typical outpatient range

›Avoid in asthma with bronchospasm

›Bradycardia and heart block precautions

›Clonidine PO

›0.1 mg to 0.2 mg single dose

›Repeat 0.1 mg hourly as needed

›Max 0.6 mg in acute setting typical

›Sedation monitoring

›Rebound hypertension risk with abrupt stop

Monitoring after oral therapy

›Observation and reassessment

›Symptom reassessment interval

›30 to 60 minutes after oral agent

›BP trend rather than single target

›Modest reduction acceptable

›Avoid precipitous fall

›Adverse effects surveillance

›Dizziness or syncope

›Bradycardia

›Bronchospasm

›Excessive sedation

Secondary cause and long term control pathway

›Triggered evaluation

›Resistant hypertension

›3 agents including diuretic with uncontrolled BP

›Hypokalemia

›Primary hyperaldosteronism consideration

›Episodic spells

›Pheochromocytoma evaluation pathway

›Sleep apnea features

›Sleep study referral

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

›Arterial stiffness

›Cerebrovascular disease

›Avoid rapid BP lowering

›Medication cautions

›Thiazide hyponatremia risk

›Sodium monitoring

›Beta blocker bradycardia risk

›Conduction disease screening with ECG if symptomatic

Pediatrics

›Pediatric definitions and approach

›BP interpretation

›Percentile based thresholds by age sex height

›Secondary cause prevalence

›Renal causes common in younger children

›Emergency red flags

›Encephalopathy

›Heart failure signs

›Disposition and specialty involvement

›Pediatrics or pediatric nephrology consultation triggers

›Severe BP confirmed

›Suspected secondary cause

›Need for weight based medication plan

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

›Evidence and guideline framing

›ACEP Clinical Policy

›Asymptomatic markedly elevated BP

›No routine ED acute lowering (ACEP Level C)

›Referral for outpatient follow-up (ACEP Level C)

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 June 16, 2026

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