Neurologic emergencies |
Hypertensive encephalopathy (typically a diagnosis of exclusion) | Mental status changes, generally without focal neurologic signs; papilledema is common | No other findings to explain mental status changes | Nitroprusside1 | 25% reduction over 2–3 hours |
Acute ischemic stroke | Focal neurologic signs, headache | CT or MRI may show infarcted or ischemic area | Nitroprusside1
(controversial) | Blood pressure is generally not treated unless it is higher than 180–220/110–120 mm Hg |
Intracranial hemorrhage | Headache, focal neurologic signs | CT or MRI typically shows hemorrhagic area | Nitroprusside1 (controversial) | 0–25% reduction over 6–12 hours (controversial) |
Subarachnoid hemorrhage | Headache | Lumbar puncture shows xanthochromia and/or blood | Nimodipine | Up to 25% reduction in previously hypertensive patients, 130–160 mm Hg systolic for normotensive patients |
Acute head injury/trauma | Headache, signs of external trauma | CT or MRI may show area of traumatized brain | Nitroprusside1 | 0–25% reduction over 2–3 hours (controversial) |
Cardiovascular emergencies |
Acute myocardial infarction | Chest discomfort, dyspnea, anxiety | Electrocardiogram may show hyperacute T-wave elevation; troponin is typically elevated | Nitroglycerin | Cessation of ischemia (typically only a 5–10% decrease is required) |
Acute left ventricular failure/acute pulmonary edema | Dyspnea, pulmonary rales | Chest x-ray shows pulmonary vascular redistribution | Nitroprusside1 or nitroglycerin | Improvement in failure (typically a 10–15% decrease) |
Acute aortic dissection | “Tearing” chest pain, pulse deficit in legs | Widened mediastinum on chest x-ray, “intimal flap” on echocardiogram, CT, or MRI | β-Blocker + nitroprusside1 | 120 mm Hg systolic in 30 minutes (if possible) |
Recent vascular surgery | Tense suture lines | None | Nitroprusside1 | Typically ˜160/100 mm Hg |
Epistaxis unresponsive to packing | Uncontrolled blood from the nose (anteriorly or posteriorly) | None | Nitroprusside1 | To control bleeding (typically only a 5–10% decrease is required) |
Renal emergencies |
Acute deterioration in renal function | None that is characteristic of this condition | Significant elevation of serum creatinine relative to recent level | Fenoldopam | 0–25% reduction in mean arterial pressure over 1–12 hours |
Hematuria (typically gross) | Red or brown urine, flank pain | 4+ blood on urinalysis | Fenoldopam | To reduce bleeding rate (typically a 0–10% reduction over 1–12 hours) |
Catecholamine-excess states |
Pheochromocytoma | Headache, sweating attacks, orthostatic hypotension | Elevated plasma metanephrines and urinary catecholamine metabolites; mass seen on CT or T2-weighted images on MRI | Phentolamine | To control paroxysms and/or symptoms |
Drug-related conditions (tyramine ingestion with monoamine oxidase inhibitor; withdrawal of antihypertensive drug; phencyclidine/cocaine use) | Headache, mental status change, tachycardia (often, but not always) | None characteristic of this condition | Phentolamine | Typically only one dose is necessary |
Pregnancy-related conditions |
Eclampsia/preeclampsia | Seizure/headache, edema (no longer required for diagnosis) | Proteinuria (dipstick or 24-hour collection); occasionally thrombocytopenia, elevated AST or ALT | MgSO4, methyldopa, hydralazine, labetalol, nifedipine | Typically <90 mm Hg diastolic, but often lower |