Management of Severe Hypertension (208/106 mmHg) After Home Medications in ED
The critical first step is to immediately assess for target organ damage to distinguish between hypertensive emergency versus urgency—this single determination dictates whether the patient needs ICU admission with IV medications or can be managed with oral therapy and outpatient follow-up. 1
Immediate Assessment Required
Evaluate for hypertensive emergency by looking for:
- Neurological: Altered mental status, severe headache, visual disturbances, focal deficits, seizures (hypertensive encephalopathy or stroke) 1
- Cardiac: Chest pain, dyspnea, signs of acute heart failure or pulmonary edema (acute coronary syndrome, left ventricular failure) 1
- Renal: Acute kidney injury with elevated creatinine, oliguria, hematuria 1
- Vascular: Tearing chest/back pain (aortic dissection) 1
- Retinal: Papilledema, hemorrhages, exudates on fundoscopy 1
Essential laboratory workup NOW:
- Complete blood count (hemoglobin, platelets for microangiopathic hemolysis) 1
- Creatinine, BUN, electrolytes (sodium, potassium) 1
- Urinalysis for protein and sediment 1
- Troponin if any chest symptoms 1
- LDH and haptoglobin if suspecting thrombotic microangiopathy 1
- ECG 1
Management Algorithm Based on Findings
If Target Organ Damage Present (Hypertensive Emergency):
Admit to ICU immediately for continuous arterial line BP monitoring and IV antihypertensive therapy. 1
Blood pressure reduction targets:
- General approach: Reduce mean arterial pressure by 20-25% within the first hour, NOT to normal 1
- Avoid excessive reduction as patients with chronic hypertension have altered autoregulation—acute normotension causes cerebral, renal, or coronary ischemia 1
First-line IV medications:
- Nicardipine: Start 5 mg/hr, titrate by 2.5 mg/hr every 15 minutes (max 15 mg/hr)—preferred for most situations due to predictable titration 1, 2
- Labetalol: Excellent for renal involvement or malignant hypertension 1
- Clevidipine: Alternative calcium channel blocker 1
If NO Target Organ Damage (Hypertensive Urgency):
This patient does NOT need immediate BP reduction in the ED. 1, 3
The patient already received appropriate home medications (amlodipine 90mg [likely 10mg] and losartan 100mg)—these will work over the next 24-48 hours. 4
Next steps:
- Observe in ED for 4-6 hours to ensure BP begins trending down and no organ damage develops 5
- Recheck BP after observation period 3
- Discharge with close outpatient follow-up within 24-48 hours to titrate medications 3
- Consider adding a thiazide-like diuretic (next step per ISH guidelines for dual therapy failure) 4
- Ensure medication compliance—non-compliance is the most common trigger for hypertensive crises 1
Critical Pitfalls to Avoid
Do NOT give additional rapid-acting antihypertensives (sublingual nifedipine, IV push medications) in hypertensive urgency—this causes unpredictable, precipitous drops leading to stroke or MI. 6, 5
Do NOT aim for normal BP acutely—target is 20-25% reduction over 24-48 hours in urgency, not normalization. 1, 5
Do NOT discharge without ensuring follow-up—recurrence rates are alarmingly high without proper outpatient management. 7
After Stabilization
Screen for secondary hypertension causes (renal artery stenosis, pheochromocytoma, primary aldosteronism)—found in 20-40% of malignant hypertension cases. 1
Address medication adherence—the most common underlying issue. 1