Hypertensive Urgency / Hypertensive Emergency Admission

Hypertensive Urgency: Severely elevated blood pressure with SBP >180 or DBP >110 without target organ damage.
Hypertensive Emergencies: Elevated blood pressure with target organ damage like CNS, CVS and the renal system.
1. Malignant Hypertension: papilledema is essential for diagnosis.
2. Accelerated Hypertension: A recent significant increase of blood pressure with associated target organ damage e.g. vascular damage on funduscopic examination with flame shaped hemorrhages or soft exudates.

ER:

Routine labs

EKG

CXR

Oxygen

Labetalol IV

Hydralazine IV-in pregnancy

By Hospitalist: 

Telemetry

Bed rest

Low salt diet

Labetalol PO if no contraindications/Hydralazine PO/Nicardipine PO/Clonidine PO

Lipid profile

Urine Toxicology

Cardiac enzymes

ECHO

Renal Arterial Duplex if Renal Arterial Stenosis suspected

Some common IV bolus medications for managing high BP:

Hydralazine 10mg IV Q 20min if needed but I prefer to use every 6hrs for SBP more than150mm Hg

Vasotec (Enalapril) 1.25-2.5 mg IV Q 6hrs

Metoprolol 2.5-5mg IV q 4hrs, I use for high BP in NPO patients who were on Beta blockers prior to admission to prevent withdrawal tachycardia.

Hypotension:

If BP is low, put patient in Trendelenburg Position.

Give IV fluid boluses with NS 2-3Liters. If patient does not respond then Epinephrine (Levophed) drip

Dopamine drip

Tests for Secondary Hypertension: 

Plasma Metanephrines, 24hr Urine Catecholamines, 24hr urine metanephrines, 24hr urine cortisol

US Retro arterial Venous duplex

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