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Acute Hypertension- Management of

The width of the bladder in the BP cuff should be at least two thirds the length of the
upper arm and completely encircle the upper arm. Inadequate bladder size can result in a
falsely elevated reading.

Patients with BP over the 95th percentile require further evaluation.

Hypertensive urgency, much more common in children, is significant elevation in BP
without accompanying end-organ damage.
Symptoms include headache, blurred vision, and nausea.

Hypertensive emergency is defined as elevation of both systolic and diastolic BP with

acute end-organ damage (e.g., cerebral infarction, pulmonary edema, hypertensive
encephalopathy, and cerebral hemorrhage).

It is important to note that the clinical differentiation between hypertensive urgencies and
hypertensive emergencies depends on end-organ damage rather than BP measurement.

Evaluate for underlying etiology:

Medication/ingestion, cardiovascular, renovascular, renal parenchymal, endocrine, or
CNS. Rule out hypertension secondary to elevated intracranial pressure (ICP) before
lowering BP.

A physical examination should include

measurement of four-extremity BP
funduscopy (papilledema, hemorrhage, exudate
visual acuity
thyroid examination
evidence for congestive heart failure (tachycardia, gallop rhythm, hepatomegaly, edema),
abdominal examination (mass, bruit),
neurologic examination
evidence of virilization,
cushingoid effect.

diagnostic evaluation

blood urea nitrogen (BUN), creatinine
chest radiograph,
Consider obtaining renin level before beginning antihypertensive therapy.
a toxicology screen, thyroid/adrenal testing, urine catecholamines,
renal Doppler ultrasound, and computed tomography (CT) of the head as indicated.

Hypertensive emergency:
IV line
arterial line for continuous BP monitoring
Seek consultation with a nephrologist or cardiologist

The goal is to lower BP promptly but gradually to preserve cerebral autoregulation.

The mean arterial pressure (MAP) (where MAP = 1/3 SBP + 2/3 DBP) should be lowered
by one third of the planned reduction over 6 hours,
an additional third over the next 24 to 36 hours,
the final third over the next 48 hours.
After elevated ICP is ruled out, do not delay treatment because of diagnostic evaluation

Note that the use of IV hydralazine may result in severe, prolonged, and uncontrollable
hypotension and is not recommended.

Hypertensive urgency:
Aim to lower MAP by 20% over 1 hour and return to baseline levels over 24 to 48 hours.
An oral route may be adequate.
Observe in the emergency department for 4 to 6 hours.
follow-up is mandatory.

use of sublingual nifedipine = can result in a precipitous, uncontrolled fall in BP.


Drug Onset (Route) Duration Comments
Interval to
Repeat or
Increase Dose
Diazoxide 1-5 min (IV) Variable (2-12 May cause
(arteriole hr) 15-30 min edema,
vasodilator) hyperglycemia


Nitroprusside <30 sec (IV) Very short 30- Requires ICU

(arteriole and 60 min setting; follow
venous thiocyanate
vasodilator) level
Labetalol (α-, 1-5 min (IV) Variable, about May require
β-blocker) 6 hr 10 min ICU setting

Nifidepine 1 min Sub lingual 3 hr 15 min May cause

(calcium edema,
channel headache,
blocker) nausea/vomiting
ICU, Intensive
care unit.


Drug Onset (Route) Duration Interval to Repeat Comments
Enalaprilat 15 min (IV) 12-24 hr 8-24 hr May cause hyperkalemia,
Minoxidil 30 min (PO) 2-5 days 4-8 hr Contraindicated in