Hypertensive Emergency

A hypertensive emergency is severely elevated BP (typically >180/120) with acute end-organ damage. The end-organ determines urgency and treatment. Hypertensive urgency (very high BP with no organ damage) can be treated with oral agents over 24–48…

Hypertensive Emergency Protocol

The pathway

1 · Confirm hypertensive emergency vs urgency

Emergency: evidence of end-organ damage (encephalopathy, acute HF, aortic dissection, AKI, eclampsia, PRES).
Urgency: very high BP alone, no organ damage.
Emergency = admit HDU/ITU.

2 · Identify the end-organ

Encephalopathy: PRES on MRI, confusion.
Heart: ACS, acute pulmonary oedema.
Aorta: tearing back/chest pain, unequal arm BPs.
Kidney: AKI, haematuria.
Pregnancy: eclampsia (seizures + proteinuria).

3 · BP reduction target

Most cases: reduce MAP by 10–20% in first hour, then further 15% over next 23h. NOT to normal — too-rapid reduction can cause ischaemic stroke, MI, blindness. Exception: aortic dissection (target SBP <120 within 20 mins).

4 · IV antihypertensive

Labetalol 20mg IV bolus, repeat up to 80mg OR infusion 2mg/min. Or sodium nitroprusside infusion (ITU). Aortic dissection: IV labetalol + esmolol. Eclampsia: labetalol or hydralazine IV.

5 · Aortic dissection pathway

CT aorta (CTPA + chest/abdo/pelvis). IV analgesia (morphine). Cardiothoracic surgery urgent referral if Type A. Target SBP <120mmHg within 20 minutes (labetalol + esmolol). Do NOT give thrombolytics.

6 · Transition to oral agents

Once BP controlled and end-organ stable: step down to oral agents. Amlodipine, bisoprolol, ramipril (once AKI excluded). Long-term BP review. Address secondary causes (phaeochromocytoma, renal artery stenosis).

Drugs

Drug	Dose	Route	Notes
Labetalol	20mg IV bolus, repeat to 80mg; or 2mg/min infusion	IV	First-line IV. Avoid in asthma, acute HF. Eclampsia-safe.
Sodium nitroprusside	0.25–8 mcg/kg/min	IV infusion	ITU only. Cyanide toxicity risk >72h or renal failure.
Hydralazine	5–10mg slowly	IV	Pregnancy/eclampsia. Can cause reflex tachycardia.
GTN infusion	Start 1–2mg/hr, titrate	IV	Hypertensive pulmonary oedema. Avoid if SBP <90.

When to escalate

Aortic dissection — cardiac surgery emergency,Hypertensive encephalopathy / PRES — neurology + ITU,Eclampsia — obstetric emergency, magnesium IV, delivery,Acute pulmonary oedema — ITU, IV nitrates + frusemide

Reference: ESC/ESH Hypertension Guidelines 2023 / NICE NG136

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