01 โ Classification & First 5 Minutes
โก The Critical First Question
High BP โ hypertensive emergency. Your job in the first 60 seconds is not to lower the number โ it's to determine if there is
acute end-organ damage (EOD). Everything flows from that answer.
Hypertensive Emergency
ACT NOW
SBP >180 or DBP >120 with acute EOD. Admit to monitored bed/ICU. IV antihypertensives. Target reduction within minutes to hours.
Hypertensive Urgency
CONTROLLED
SBP >180 or DBP >120 without EOD. Oral agents, gradual reduction over 24โ48h. Most patients discharged with follow-up.
Pseudocrisis / White Coat
OBSERVE
Elevated reading driven by pain, anxiety, missed dose, caffeine. No EOD, resolves spontaneously or with anxiolysis. Biggest trap in the ER.
Elevated BP in Stroke
SPECIAL RULES
Reflex response โ often protective. Do NOT lower empirically. Stroke protocol overrides everything here.
๐ง Neurological
- Hypertensive encephalopathy
- Hypertensive PRES
- Intracranial hemorrhage
- Ischemic stroke (different rules!)
โค๏ธ Cardiac
- Acute coronary syndrome
- Acute decompensated HF / pulm edema
- Aortic dissection
๐ซ Renal
- Hypertensive nephrosclerosis (acute)
- Microangiopathic hemolytic anemia
๐๏ธ Ophthalmologic
- Grade IIIโIV retinopathy
- Papilledema
๐คฐ Obstetric
- Severe preeclampsia
- Eclampsia โ MgSO4 + delivery
- HELLP syndrome
T = 0
Bilateral arm BPs, HR, SpO2, GCS/orientation, RR. Note: is the difference between arms >20 mmHg? โ dissection until proven otherwise
T = 1โ2 min
Targeted history: onset of current BP level, baseline BP, known HTN & meds, last dose taken, symptoms (headache, vision, CP, SOB, neuro deficit, pregnancy)
T = 2โ3 min
Focused exam: fundoscopy if available (papilledema?), chest auscultation, neuro screen, abdo tenderness, JVP/pedal edema
T = 3โ5 min
IV access x2, send bloods, ECG, CXR โ decide: Emergency vs Urgency. Do not start antihypertensive before this decision.
02 โ Workup & Orders
๐ Ordering Philosophy
Order targeted, not shotgun. Every test should answer a specific clinical question. Below is stratified by what you're looking for.
Renal panel
Creatinine, BUN/ureum, eGFR โ acute hypertensive nephropathy? Baseline for nephrotoxic drug risk?
Electrolytes
Na, K โ hypokalemia suggests secondary HTN (hyperaldosteronism); K crucial before starting loop diuretics
Urinalysis
Dipstick + microscopy. Hematuria, proteinuria, RBC casts = hypertensive nephropathy / glomerulonephritis
CBC
Thrombocytopenia + fragmented RBCs โ thrombotic microangiopathy (TMA/HUS/TTP context)
Blood glucose
Exclude hypoglycemia as cause of neurological symptoms
Cardiac / ACS
ECG (LVH, ST changes, strain pattern), Troponin I/T, CK-MB, CXR (cardiomegaly, pulm edema)
Aortic dissection
BP difference both arms, wide mediastinum on CXR โ CT angiography chest-abdomen-pelvis urgently. D-dimer negative helps rule out but don't rely on it alone.
Neurological
Non-contrast CT head first (exclude hemorrhage). If PRES suspected โ MRI (T2 FLAIR). Fundoscopy for papilledema.
Pulmonary edema
CXR (bat-wing infiltrates, Kerley B lines, cephalization), BNP/NT-proBNP, ABG if respiratory distress
Obstetric
Urine protein:creatinine ratio or 24h protein, LFTs, LDH, uric acid, platelet count (HELLP screen). Obstetrics consult.
Secondary HTN screen
Young patient, resistant, hypokalemic: aldosterone:renin ratio, serum cortisol, urine catecholamines (pheochromocytoma).
- Non-adherence โ most common reason; always ask last dose + confirm they have the meds
- NSAIDs โ sodium retention, antagonize antihypertensives
- Oral contraceptives โ especially combined pill
- Sympathomimetics โ decongestants, pseudoephedrine, methamphetamine, cocaine
- Clonidine withdrawal โ classic rebound crisis
- Erythropoietin in CKD patients
- Steroids (chronic), tacrolimus, cyclosporine
03 โ BP Targets by Scenario
โ ๏ธ Core Principle
Autoregulation is reset in chronic HTN. A "normal" BP of 120/80 can cause ischemia in someone chronically running at 180/100.
Reduce gradually. The speed matters as much as the target.
| Scenario |
Initial Target |
Timeline |
Notes |
| Hypertensive encephalopathy |
โ MAP by 25% |
1 hour |
Then gradual to 160/100 over 2โ6h |
| Acute pulmonary edema |
โ MAP by 25% |
30โ60 min |
Nitrates ยฑ loop diuretic; avoid in low EF without support |
| ACS / NSTEMI |
<140/90 |
1 hour |
IV nitrates + beta-blocker; aggressive BP lowering if ongoing ischemia |
| Aortic dissection (Type A/B) |
SBP 100โ120, HR <60 |
Minutes |
Most time-critical. Beta-blocker first, then vasodilator. Surgery consult immediately for Type A. |
| ICH (Hemorrhagic stroke) |
SBP <140 (if 150โ220) |
1 hour |
If SBP >220 โ more aggressive. Controversial, AHA 2022 says target <140 is reasonable. |
| Ischemic stroke (no lysis) |
SBP <220 / DBP <120 |
Do NOT lower |
Unless >220/120: permissive hypertension. Treat if associated with ACS/dissection. |
| Post-thrombolysis stroke |
SBP <180 / DBP <105 |
Maintain 24h |
Risk of hemorrhagic transformation if not controlled |
| Hypertensive urgency (no EOD) |
160/100 target |
24โ48 hours |
Oral agents, no need for IV. Do not be aggressive. |
| Eclampsia / severe preeclampsia |
SBP <160, DBP <105 |
30โ60 min |
MgSO4 for seizure prophylaxis. Hydralazine or nifedipine oral. Definitive = delivery. |
| Pheochromocytoma crisis |
โ MAP by 25% |
Minutes |
Alpha-blocker FIRST (phentolamine). Never give beta-blocker alone โ paradoxical worsening. |
| Acute renal failure (hTN) |
โ MAP by 25% |
1โ6 hours |
Avoid excessive reduction โ can worsen renal perfusion |
๐ MAP Formula Reminder
MAP = DBP + 1/3(SBP โ DBP) | Or: MAP โ (SBP + 2รDBP) / 3
A 25% MAP reduction from e.g. MAP 160 โ target MAP ~120
04 โ Drug Selection by EOD
๐ก Selection Logic
Match mechanism to pathophysiology. The question is never just "what lowers BP fastest" โ it's "what helps this specific end-organ while lowering BP."
Dihydropyridine CCB ยท Vasodilator ยท No reflex tachycardia at therapeutic doses
Starting dose
5 mg/h IV infusion
Titration
โ by 2.5 mg/h q5โ15 min. Max 15 mg/h
Duration
4โ6 hours after stop
Preparate (ID)
10 mg/10 mL per ampoule. Mix in NS or D5%.
Best for
Hypertensive encephalopathy, post-op, perioperative, most emergencies without cardiac failure
Avoid in
Acute decompensated HF (negative inotropy), severe aortic stenosis
Advantage
Titratable, cerebrovascular-friendly, preserves coronary flow
Nitric oxide donor ยท Venodilator (low dose) โ arterial dilator (high dose)
Dose range
5โ100 ยตg/min IV. Titrate q3โ5 min.
Preparate (ID)
5 mg/10 mL or 10 mg/10 mL per ampoule. Use PVC-free set (absorbs GTN).
Best for
Acute pulmonary edema, ACS-associated HTN, HF with HTN. Reduces preload primarily.
Avoid in
Hypotension, RV infarction, PDE5 inhibitor use (sildenafil), severe aortic stenosis, tachycardia
Caution
Tachyphylaxis within 24โ48h. Methemoglobinemia at high doses.
Combined ฮฑ+ฮฒ blocker ยท No reflex tachycardia ยท Reduces HR
Bolus
20 mg slow IVP, then 40โ80 mg q10 min. Max cumulative 300 mg.
Infusion
0.5โ2 mg/min IV infusion
Preparate (ID)
100 mg/20 mL per ampoule (less commonly stocked)
Best for
Aortic dissection (with nitroprusside), eclampsia, sympathomimetic-induced crisis, catecholamine excess
Avoid in
Acute decompensated HF, bradycardia, high-degree AV block, reactive airway disease/asthma, PHEO alone
Balanced arteriovenous dilator ยท Fastest onset, most titratable, highest risk
Dose
0.3โ10 ยตg/kg/min IV. Start low. Titrate to response.
Onset
<1 minute. Duration 1โ2 min after stop.
Preparate (ID)
50 mg/vial. Must be light-protected. Mix 50 mg in 250 mL D5%.
Best for
When nothing else is available/effective. Aortic dissection (with beta-blocker). Hypertensive emergency refractory to other agents.
Cyanide toxicity
Avoid >2 ยตg/kg/min >10 min in renal/hepatic impairment. Co-infuse thiosulfate if high doses. Signs: metabolic acidosis, altered consciousness.
Avoid in
Pregnancy, elevated ICP, coronary steal risk, hepatic failure. Use only if you have intra-arterial BP monitoring or can do q2โ5 min manual BPs.
Captopril SL/oral
6.25โ25 mg PO. Onset 15โ30 min. Workhorse in ID ER for urgency. Avoid in bilateral RAS, pregnancy.
Nifedipine oral
5โ10 mg PO (NOT sublingual โ unpredictable, can precipitate ischemia). Onset 20โ30 min.
Clonidine oral
0.1โ0.2 mg PO, repeat q1h prn. Max 0.7 mg. Good for opioid/alcohol withdrawal context. Rebound on abrupt stop.
Amlodipine oral
5โ10 mg PO once. Not for acute control (onset 6โ12h) but good for starting chronic therapy.
โ ๏ธ Sublingual Nifedipine โ Avoid
Sublingual nifedipine causes rapid, unpredictable BP drop โ stroke, MI, death reported. It is
NOT recommended in any current guideline. Oral formulation only.
First line
Hydralazine 5โ10 mg IV bolus slowly, repeat q20 min. Or nifedipine 10 mg oral q20 min x3.
Seizure prophylaxis
MgSO4: 4g IV over 20 min, then 1โ2 g/h infusion. Monitor Mg toxicity: UO, reflexes, RR.
Avoid
ACE inhibitors (fetotoxic), nitroprusside (cyanide), atenolol (IUGR)
Definitive Rx
Delivery after โฅ34 weeks. Obstetrics manages โ your role is BP stabilization.
05 โ Infusion Rate Calculator
โน๏ธ Usage
Select drug โ enter how much drug you're adding to the bag (ampoule reference shown below the field) โ enter diluent volume โ enter desired dose. Concentration is calculated live from what you actually mixed.
Nicardipine ยท 10 mg/10 mL per ampoule
Mix: 3 ampoules (30mg) in 120mL NS โ 0.2 mg/mL
Or: 1 ampoule (10mg) in 90mL NS โ 0.1 mg/mL
5 mg/h at 0.1 mg/mL โ 50 mL/h
5 mg/h at 0.2 mg/mL โ 25 mL/h
10 mg/h at 0.2 mg/mL โ 50 mL/h
15 mg/h at 0.2 mg/mL โ 75 mL/h
Nitroglycerin ยท 5 mg/10 mL or 10 mg/10 mL per ampoule
Mix: 50mg in 250mL D5% โ 200 ยตg/mL
Or: 25mg in 250mL D5% โ 100 ยตg/mL
5 ยตg/min at 100 ยตg/mL โ 3 mL/h
10 ยตg/min at 100 ยตg/mL โ 6 mL/h
20 ยตg/min at 100 ยตg/mL โ 12 mL/h
50 ยตg/min at 100 ยตg/mL โ 30 mL/h
100 ยตg/min at 100 ยตg/mL โ 60 mL/h
โ Use PVC-free administration set (GTN absorbs to PVC tubing)
Nitroprusside ยท 50 mg/vial ยท LIGHT PROTECT
Mix: 50mg in 250mL D5% โ 200 ยตg/mL
Dose: 0.3โ10 ยตg/kg/min
For 60 kg patient at 0.5 ยตg/kg/min:
= 60 ร 0.5 = 30 ยตg/min = 1800 ยตg/h
At 200 ยตg/mL โ 9 mL/h
โ Wrap bag + tubing in aluminum foil / opaque cover
โ Max duration: change bag q24h. Cyanide risk >2 ยตg/kg/min prolonged
MgSO4 40% solution (4g/10mL ampoule)
Loading dose: 4g (10 mL of 40%) in 100mL NS over 20 min
Maintenance: 1โ2 g/h
= 6g in 100mL NS at 16โ33 mL/h (for 1โ2 g/h)
Monitor every hour:
โ UO >25 mL/h | โ RR >12/min | โ Patellar reflexes present
โ Toxicity: RR <12, loss of reflexes, hypotension, cardiac arrest
Antidote: Calcium gluconat 10% 10mL IV over 10 min
06 โ Monitoring, Reassessment & When to Rethink
q5'
BP while titrating
Until stable
q15'
BP after stable target
First 1โ2 hours
q1h
Neuro checks
Encephalopathy cases
Cont.
SpO2 + cardiac monitor
All IV agents
q1h
Urine output
Insert IDC if renal concern
q6โ12h
Repeat creatinine / electrolytes
If renal involvement
Too fast โ BP
New symptoms: altered consciousness, new focal neuro deficit, chest pain, โUO โ stop infusion, give 250mL NS bolus if indicated, reassess
Hypotension
SBP <90 or MAP <65 โ stop vasoactive, fluid resuscitate. Look for another diagnosis (sepsis, bleed, tamponade).
Tachycardia
Reflex tachycardia with nitroprusside or nicardipine โ consider adding beta-blocker. HR >110 at rest is a red flag.
No response
SBP >200 despite 2 agents at adequate dose โ think secondary HTN: pheochromocytoma, renal artery stenosis, hyperaldosteronism. Escalate care.
Transitioning out
Overlap with oral agent 1โ2h before stopping IV infusion. Do not stop IV abruptly without oral agent on board.
T = 30 min
Has BP moved toward target? Is the patient better or worse symptomatically? Any new symptoms?
T = 1 hour
Am I at target range? Has end-organ status improved (neuro, renal, resp)? Am I on the right drug for this EOD type?
T = 2โ4 hours
Is my diagnosis correct? Did I miss dissection? Is there a secondary cause? Plan for oral transition.
T = 6โ12 hours
Oral agent working? Can IV be weaned? Disposition: ICU, ward, or safe discharge?
Discharge
Does the patient have meds? Can they afford them? Do they have a follow-up plan? Discharge without these = guaranteed readmission.
07 โ Pits & Pearls
โ Pit
Treating the number, not the patient. A BP of 220/130 in a chronic hypertensive with no symptoms may need nothing more than restart of their home medications. A BP of 180/110 with papilledema and confusion needs your full attention immediately.
๐ Pearl
The bilateral arm BP trick. Always check both arms. Discrepancy >20 mmHg suggests aortic dissection until proven otherwise. This is one of the highest-yield bedside maneuvers you can do.
โ Pit
Sublingual nifedipine. Still used widely in Indonesian ERs. It is associated with unpredictable BP drops and has been linked to MI, stroke, and death. This practice should be abandoned. Oral nifedipine only.
๐ Pearl
Permissive hypertension in ischemic stroke. The hypertension is often a protective Cushing response. Aggressively lowering BP in ischemic stroke can extend the penumbra and kill the patient faster. Do NOT touch BP unless >220/120 or there's another reason (thrombolysis, concurrent ACS).
โ Pit
Beta-blocker alone in pheochromocytoma. Giving propranolol or metoprolol without alpha-blockade first โ paradoxical severe hypertension from unopposed alpha-adrenergic tone. Alpha first (phentolamine), then beta. Always.
๐ Pearl
Pain drives BP. In a trauma patient or someone in acute pain, treat the pain first. You'll be amazed how often the BP normalizes. This is the most underappreciated "antihypertensive" in the ER.
โ Pit
Missing aortic dissection. Atypical presentations (abdo pain, syncope, neurology) without chest pain. Any hypertensive emergency + pulse deficit + BP asymmetry โ CT angiography before starting vasodilators. Nitroprusside in an unoperated Type A dissection buys you time but the patient still needs the OR.
๐ Pearl
White coat effect is real and common. Sit the patient, control pain, re-measure after 10 min of rest. If BP normalizes and they're asymptomatic, you just saved them from unnecessary IV medications and an ICU admission. Document your reasoning.
โ Pit
ACE inhibitor in bilateral renal artery stenosis or solitary kidney. Removing efferent arteriole tone โ precipitous AKI. Know your patient's renal anatomy before reaching for captopril.
๐ Pearl
The "floor" in chronic hypertensives. Their autoregulation curve is shifted right. A MAP of 80 that is "normal" can be ischemic for their brain and kidneys. When reducing BP, go no more than 25% of MAP in the first hour. Slower is safer in all EOD except dissection and eclampsia.
โ Pit
Stopping IV without oral overlap. When nicardipine or GTN is stopped, BP rebounds fast if no oral agent has been started. Start the oral agent 1โ2 hours before you plan to wean the IV.
๐ Pearl
Nicardipine is your friend in Indonesia. It is widely available, has predictable kinetics, no cyanide risk, doesn't need light protection, and is safe across most EOD scenarios. Make it your default IV agent unless there's a specific contraindication or a more targeted drug is indicated.
โ Pit
Diagnosing hypertensive urgency in the ED without confirming no EOD. Before calling it "urgency," you must have actively looked for EOD โ not just assumed. A brief fundoscopy, neuro exam, and urinalysis takes 5 minutes. Skipping these is how papilledema gets missed.
๐ Pearl
Discharge planning IS part of emergency management. A hypertensive urgency patient who leaves without affordable medications and a concrete follow-up will return in 48โ72 hours in crisis. The prescription pad is as important as the drip pump.