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Hypertensive emergency
It's the organ damage, not the number, that makes it an emergency. Severe hypertension with acute organ damage needs controlled IV treatment in a monitored bed. Without organ damage, lowering the BP quickly does more harm than good. Built for revision, not live patient decisions.
Settle them, and check the basics
emergency or urgency?Red flags — what each should make you think
The biggest mistake is lowering a very high BP too fast in someone without organ damage. The brain and kidneys have adapted to the high pressure, and a sudden drop can cause stroke or kidney injury. Recheck the BP after rest and analgesia before deciding anything.
Hypertensive emergency (BP often ≥180/120 with acute organ damage)
- 📍Monitored bed
- IVIV agent by indication
- ↓25%Lower the mean arterial pressure gradually
- 🔍Look for organ damage
- 🤰Pregnancy test
- ☎Senior early
Understand the patient — targets by condition
one size doesn't fit allCondition-specific targets (guide only — check local protocols)
- Aortic dissection — rapidly: SBP under 120 and HR under 60 within minutes, usually with IV labetalol or esmolol first
- Acute ischaemic stroke — if thrombolysis planned, BP must be under 185/110 before and kept under 180/105 for 24 h; otherwise usually leave it unless very high
- Intracerebral haemorrhage — NICE: if presenting within 6 h with SBP 150–220, lower to 130–140 within 1 hour (not below 130)
- Pre-eclampsia — treat if ≥160/110, aiming for under 135/85 (labetalol, nifedipine, hydralazine); give magnesium if severe
- Pulmonary oedema / ACS — IV nitrates, CPAP for oedema
- Cocaine/amphetamines — benzodiazepines first; avoid beta-blockers alone
Urgency (no acute organ damage)
- Recheck after rest and analgesia (pain, anxiety, urinary retention, withdrawal all raise BP)
- Start or adjust oral treatment and arrange prompt review
- NICE: same-day specialist referral if BP ≥180/120 with retinal haemorrhage or papilloedema, or life-threatening symptoms, or suspected phaeochromocytoma
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Abrupt severe chest or back pain, pulse or BP difference between arms, neuro deficit, new AR murmur.
CT aortogram.
IV beta-blocker first (rate before vasodilator), then vasodilator, analgesia; cardiothoracic (type A) or vascular (type B).
Headache, vomiting, confusion, seizures, cortical blindness with severe hypertension.
Clinical, MRI (posterior oedema), exclude stroke/bleed on CT.
Controlled IV reduction (about 25% MAP over the first hours), treat seizures.
Sudden focal deficit, headache, vomiting, reduced GCS.
CT head.
BP lowering to target, reverse anticoagulation, neurosurgical/stroke team.
Over 20 weeks pregnant or up to 6 weeks postpartum with hypertension, headache, visual disturbance, RUQ pain, seizures.
Urine protein:creatinine ratio, FBC, LFT, U&E, sFlt-1/PlGF.
Obstetric emergency team; antihypertensives, magnesium sulfate for severe disease/eclampsia.
Very high BP with retinal haemorrhages/exudates/papilloedema, AKI, haemolysis (thrombotic microangiopathy).
Fundoscopy, U&E, FBC + film, LDH, urine dip.
Controlled IV lowering; renal team.
Investigate — what to order, when, and what it tells you
test with a question in mindOrgan damage screen
Imaging
Other
How the plan comes together
disposition · handoverhome with follow-up
Severe hypertension, no organ damage, settled after rest: start/adjust oral treatment, GP or hypertension clinic review within days.
HDU / specialist
Any acute organ damage, dissection, stroke/ICH, pre-eclampsia, encephalopathy.
Hand over: organ damage found, agent and rate, BP target and timeframe.
First ask whether there's organ damage. If yes, lower the BP in a controlled way to a condition-specific target. If not, lower it slowly and arrange follow-up. Nicely done getting here.
Clerking template
copy or downloadHypertensive emergency — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 12 knownFrequently asked questions
quick answersWhat are the red flags for hypertensive emergency?
- Headache, confusion, seizures, visual loss — think hypertensive encephalopathy
- Papilloedema / retinal haemorrhages — think malignant hypertension
- Tearing chest/back pain — think aortic dissection
- Focal neurology — think stroke / ICH
- Pregnant or postpartum — think pre-eclampsia / eclampsia
- Breathless, crackles — think hypertensive pulmonary oedema
- Chest pain, ECG changes — think ACS
- Cocaine / amphetamines — think sympathomimetic crisis
What is the initial management of hypertensive emergency?
- Monitored bed — HDU/resus; arterial line for IV infusions
- IV agent by indication — labetalol, GTN, nicardipine or clevidipine, per local protocol and senior advice
- Lower the mean arterial pressure gradually — generally by no more than 25% in the first hours (except dissection and some strokes)
- Look for organ damage — fundoscopy, ECG, troponin, U&E, urine dip, CT head if neuro
- Pregnancy test — women of childbearing age
- Senior early — condition-specific targets differ
Always alongside senior support and your local guideline.
What diagnoses must you not miss in hypertensive emergency?
- Aortic dissection — tearing pain · lower fast
- Hypertensive encephalopathy / PRES — headache · confusion · fits
- Intracerebral haemorrhage — focal · sudden
- Pre-eclampsia / eclampsia — pregnant · postpartum
- Malignant hypertension with AKI — retinopathy · renal
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for hypertensive emergency?
- Organ damage screen — LVH, ischaemia.
- Imaging — Neuro symptoms.
- Other — Haemorrhages, exudates, papilloedema.
Admit or discharge: how is the plan decided for hypertensive emergency?
- Home with follow-up — Severe hypertension, no organ damage, settled after rest: start/adjust oral treatment, GP or hypertension clinic review within days.
- Hdu / specialist — Any acute organ damage, dissection, stroke/ICH, pre-eclampsia, encephalopathy.
Is there a clerking template for hypertensive emergency?
Yes — there is a free clerking template for hypertensive emergency on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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