Hypertensive Emergencies Algorithm

HTN Emergency is when a patient has high blood pressure (especially if >180/120mmhg) with features of progressive or impending end organ damage.

Monitor, support ABCs, check vital signs, start oxygen if SPO2 is <94% establish IV access and send samples for CBC, UECS, urinalysis (for proteinuria) and PDT if applicable.

Obtain/review 12 lead ECG, perform a brief, targeted history and physical exam, Consult a physician or obstetrician for eclampsia.

Neurological emergencies:
Hypertensive Encephalopathy-Reduce MAP immediately by 20%-25%.

Drugs- labetalol, nicardipine, nitroprusside.

Acute ischemic stroke-In patients with markedly raised blood pressure-(>220/120) who do not receive fibrinolysis, a reasonable goal is to lower blood pressure by 25% in the first 24 hours after onset of stroke. With indication for fibrinolysis with a bp >185/110mmhg, reduce MAP by 15% in the first hour.

Drugs- labetalol, nicardipine, nitroprusside. If BP is not maintained or below 180/105mmhg, do not administer rTPA.

After fibrinolysis the blood pressure should be maintained <180/105mmhg.

Acute hemorrhagic stroke and SBP>180mmhg
No evidence suggests that HTN provokes further bleeding in patients with intracranial hemorrhage.
A precipitus fall in SBP may compromise cerebral perfusion and increase mortality. Reduce MAP just below 130 or SBP <180 immediately.

Drugs: Labetalol, nicardipine.

Subarachnoid hemorrhage:
Maintain SBP <160mmhg until the aneurysm is treated or cerebral vasospasms occur. Oral nimodipine is indicated to prevent delayed ischemic neurologic deficits but not to treat hypertension.

Cardiovascular emergencies

Acute coronary event
Reduce MAP <140 immediately. Thrombolytics are contraindicate in bps>180/100mmhg.

Drugs: labetalol, nitroglycerine.

Acute cardiogenic pulmonary oedema Reduce MAP <140 immediately

drugs: nitroprusside or nitroglycerine with a loop diuretic.

Acute aortic disease:
Immediately reduce BP to <120mmhg and heart rate <60bpm.Maintain it at this level until signs of hypoperfusion are present.

Drugs :nitropruside or nitroglycerine or nicardipine,labetalol/metoprolol, avoid betablockers if there is aortic valvular regurgitation suspected cardiac tamponade.

Cocaine toxicity/ pheochromocytoma: hypertension and tachycardia rarely require treatment.
Benzodiazepines are the recommended treatment for acute coronary syndromes.
Pheochromocytoma:similar treatment as cocaine toxicity.Beta blockers can be used to control bp only after alpha blockade.

drugs: diazepam, nitroprusside, nitroglycerine, phentolamine. AVOID beta adrenergic antagonists before giving phentolamine.

Preeclampsia/eclampsia:

BP should be <160/110mmhg in the prepartum and intrapaturm phase.

Maintain below 150/100mmhg if platelets are below 100,000cells /mm.

Close monitoring (invasive, if clinically indicated)

Drugs:MgSo4, hydralazine, labetalol, nifedipine

Familiarity with second-line medications phenytoin and diazepam/lorazepam is required for cases in which magnesium sulfate may be contraindicated (eg, myasthenia gravis) or ineffective.

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