What are the prescription templates for managing hypertensive emergencies in various clinical scenarios?

Prescription Templates for Hypertensive Emergencies

General Principles

All hypertensive emergencies (BP >180/120 mmHg with acute end-organ damage) require immediate ICU admission with continuous IV antihypertensive therapy, not oral agents. 1

Blood Pressure Reduction Targets

For patients WITHOUT compelling conditions (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma):

• Reduce SBP by maximum 25% within first hour 1
• Then target 160/100 mmHg over next 2-6 hours if stable 1
• Gradually normalize BP over following 24-48 hours 1

For patients WITH compelling conditions:

• Aortic dissection: Reduce SBP to <120 mmHg within 20 minutes 1
• Severe preeclampsia/eclampsia or pheochromocytoma: Reduce SBP to <140 mmHg within first hour 1

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Scenario 1: Acute Aortic Dissection

Prescription Template:

Esmolol IV:
- Loading dose: 500-1000 mcg/kg over 1 minute
- Maintenance infusion: 50 mcg/kg/min
- Titrate by 50 mcg/kg/min increments every 5 minutes
- Maximum: 200 mcg/kg/min
- Target: SBP ≤120 mmHg within 20 minutes

If additional BP control needed, ADD:
Nicardipine IV:
- Start: 5 mg/hr
- Increase by 2.5 mg/hr every 5 minutes
- Maximum: 15 mg/hr

OR Sodium Nitroprusside IV:
- Start: 0.3-0.5 mcg/kg/min
- Titrate by 0.5 mcg/kg/min increments
- Maximum: 10 mcg/kg/min

Critical: Beta blockade MUST precede vasodilator administration to prevent reflex tachycardia and increased aortic shear stress. 1

Alternative if beta blockers contraindicated:

Labetalol IV (combined alpha/beta blocker):
- Initial bolus: 0.3-1.0 mg/kg (maximum 20 mg) over 2 minutes
- Repeat every 10 minutes as needed
- OR continuous infusion: 0.4-1.0 mg/kg/hr up to 3 mg/kg/hr
- Maximum cumulative: 300 mg

1

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Scenario 2: Acute Pulmonary Edema

Prescription Template:

Nitroglycerin IV (FIRST-LINE):
- Start: 5 mcg/min
- Increase by 5 mcg/min every 3-5 minutes
- Maximum: 20 mcg/min
- Target: Symptom relief and BP reduction

OR Clevidipine IV:
- Start: 1-2 mg/hr
- Double dose every 90 seconds until BP approaches target
- Then increase by 

CONTRAINDICATION: Beta blockers are absolutely contraindicated in acute pulmonary edema. 1

Caution: Do not use nitroglycerin in volume-depleted patients or with concurrent PDE-5 inhibitor use (risk of profound hypotension). 1

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Scenario 3: Acute Coronary Syndrome (ACS)

Prescription Template:

Nitroglycerin IV (AGENT OF CHOICE):
- Start: 5 mcg/min
- Increase by 5 mcg/min every 3-5 minutes
- Maximum: 20 mcg/min

PLUS Esmolol IV (AGENT OF CHOICE):
- Loading dose: 500-1000 mcg/kg over 1 minute
- Maintenance: 50 mcg/kg/min
- Titrate by 50 mcg/kg/min every 5 minutes
- Maximum: 200 mcg/kg/min

Alternative options:
Labetalol IV:
- Bolus: 0.3-1.0 mg/kg (max 20 mg) every 10 minutes
- OR infusion: 0.4-1.0 mg/kg/hr up to 3 mg/kg/hr

OR Nicardipine IV:
- Start: 5 mg/hr
- Increase by 2.5 mg/hr every 5 minutes
- Maximum: 15 mg/hr

1

Beta blocker contraindications in ACS: Moderate-to-severe LV failure with pulmonary edema, bradycardia (<60 bpm), hypotension (SBP <100 mmHg), poor peripheral perfusion, second- or third-degree heart block, reactive airways disease. 1

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Scenario 4: Acute Renal Failure

Prescription Template:

Fenoldopam IV (PREFERRED - improves renal blood flow):
- Start: 0.1-0.3 mcg/kg/min
- Increase by 0.05-0.1 mcg/kg/min every 15 minutes
- Maximum: 1.6 mcg/kg/min

OR Clevidipine IV:
- Start: 1-2 mg/hr
- Double every 90 seconds until BP approaches target
- Then increase by 

1

Fenoldopam offers specific advantage of causing natriuresis and improving renal perfusion. 2

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Scenario 5: Eclampsia or Severe Preeclampsia

Prescription Template:

Hydralazine IV (DRUG OF CHOICE):
- Initial: 10 mg slow IV infusion (maximum initial dose 20 mg)
- Repeat every 4-6 hours as needed
- Onset: 10-30 minutes
- Duration: 2-4 hours

OR Labetalol IV:
- Bolus: 0.3-1.0 mg/kg (max 20 mg) every 10 minutes
- OR infusion: 0.4-1.0 mg/kg/hr up to 3 mg/kg/hr
- Maximum cumulative: 300 mg

OR Nicardipine IV:
- Start: 5 mg/hr
- Increase by 2.5 mg/hr every 5 minutes
- Maximum: 15 mg/hr

ABSOLUTE CONTRAINDICATIONS: ACE inhibitors, ARBs, renin inhibitors, and sodium nitroprusside are contraindicated in pregnancy. 1

Target: Rapid BP lowering required, SBP <140 mmHg within first hour. 1

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Scenario 6: Pheochromocytoma Crisis / Catecholamine Excess

Prescription Template:

Phentolamine IV (DRUG OF CHOICE):
- Bolus: 5 mg IV
- Repeat every 10 minutes as needed to lower BP to target

PLUS (for tachycardia control AFTER alpha blockade):
Esmolol IV:
- Loading: 500-1000 mcg/kg over 1 minute
- Maintenance: 50 mcg/kg/min
- Titrate by 50 mcg/kg/min every 5 minutes
- Maximum: 200 mcg/kg/min

Alternative vasodilators (after alpha blockade):
Clevidipine IV:
- Start: 1-2 mg/hr
- Titrate as above

OR Nicardipine IV:
- Start: 5 mg/hr
- Titrate as above

Critical: NEVER give beta blockers before alpha blockade in pheochromocytoma - this causes unopposed alpha stimulation and worsening hypertensive crisis. 1

Also used for: Cocaine toxicity, amphetamine overdose, MAO inhibitor interactions, clonidine withdrawal. 1

Phentolamine contraindications: Increased intraocular pressure (glaucoma), increased intracranial pressure, sulfite allergy. 1

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Scenario 7: Perioperative Hypertension

Prescription Template:

Clevidipine IV (PREFERRED - rapid titration):
- Start: 1-2 mg/hr
- Double every 90 seconds until BP approaches target
- Then increase by 

Definition: BP ≥160/90 mmHg OR SBP elevation ≥20% of preoperative value persisting >15 minutes. 1

Most common timing: During anesthesia induction and airway manipulation. 1

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Scenario 8: Hypertensive Encephalopathy (No Stroke)

Prescription Template:

Nicardipine IV (FIRST-LINE):
- Start: 5 mg/hr
- Increase by 2.5 mg/hr every 5 minutes
- Maximum: 15 mg/hr
- No dose adjustment needed for elderly

OR Labetalol IV:
- Bolus: 0.3-1.0 mg/kg (max 20 mg) every 10 minutes
- OR infusion: 0.4-1.0 mg/kg/hr up to 3 mg/kg/hr
- Maximum cumulative: 300 mg

OR Clevidipine IV:
- Start: 1-2 mg/hr
- Double every 90 seconds until BP approaches target
- Then increase by 

Avoid sodium nitroprusside if possible due to risk of increased intracranial pressure and cyanide toxicity. 1, 3

Target: Reduce SBP by maximum 25% in first hour, then to 160/100 mmHg over 2-6 hours. 1

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Scenario 9: Acute Myocardial Infarction with Hypertension

Prescription Template:

Nitroglycerin IV (FIRST-LINE):
- Start: 5 mcg/min
- Increase by 5 mcg/min every 3-5 minutes
- Maximum: 20 mcg/min

PLUS Beta blocker (if no contraindications):
Esmolol IV:
- Loading: 500-1000 mcg/kg over 1 minute
- Maintenance: 50 mcg/kg/min
- Titrate by 50 mcg/kg/min every 5 minutes
- Maximum: 200 mcg/kg/min

OR Labetalol IV:
- Bolus: 0.3-1.0 mg/kg (max 20 mg) every 10 minutes
- OR infusion: 0.4-1.0 mg/kg/hr up to 3 mg/kg/hr

1

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Scenario 10: Unstable Angina with Severe Hypertension

Prescription Template:

Nitroglycerin IV (AGENT OF CHOICE):
- Start: 5 mcg/min
- Increase by 5 mcg/min every 3-5 minutes
- Maximum: 20 mcg/min

PLUS (if no contraindications):
Esmolol IV:
- Loading: 500-1000 mcg/kg over 1 minute
- Maintenance: 50 mcg/kg/min
- Titrate by 50 mcg/kg/min every 5 minutes
- Maximum: 200 mcg/kg/min

Alternative:
Nicardipine IV:
- Start: 5 mg/hr
- Increase by 2.5 mg/hr every 5 minutes
- Maximum: 15 mg/hr

1

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Critical Administration Details

Nicardipine IV Administration 4:

Dilution (single dose vials):
- Each 25 mg vial diluted with 240 mL compatible IV fluid
- Final concentration: 0.1 mg/mL

Compatible fluids:
- Dextrose 5%
- Dextrose 5% + NaCl 0.45% or 0.9%
- Dextrose 5% + 40 mEq Potassium
- NaCl 0.45% or 0.9%

INCOMPATIBLE: Sodium Bicarbonate 5%, Lactated Ringer's

Administration:
- Via central line OR large peripheral vein
- Change infusion site every 12 hours if peripheral
- Protect from light until use
- Stable for 24 hours at room temperature

Sodium Nitroprusside Critical Safety 1:

Cyanide toxicity prevention:
- For infusion rates ≥4-10 mcg/kg/min OR duration >30 minutes:
  Co-administer sodium thiosulfate

Monitoring:
- Intra-arterial BP monitoring recommended
- Use shortest duration possible
- Lower doses required for elderly

Toxicity signs:
- Irreversible neurological changes
- Cardiac arrest
- Tachyphylaxis with extended use

Clevidipine Contraindications 1:

• Soybean, soy product, egg, or egg product allergy
• Defective lipid metabolism (pathological hyperlipidemia, lipoid nephrosis, acute pancreatitis)
• Use low-end dose range for elderly patients
• Maximum duration: 72 hours

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Drugs to AVOID in Hypertensive Emergencies

NEVER USE: 5, 3, 6

• Immediate-release nifedipine (causes uncontrolled BP drops, stroke, death)
• Oral agents for true emergencies (inadequate control, unpredictable response)
• Hydralazine as first-line (unpredictable response, prolonged duration except in eclampsia)

USE WITH EXTREME CAUTION:

• Sodium nitroprusside (cyanide toxicity, increased ICP, requires arterial line monitoring) 1, 5, 3

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Monitoring Requirements

All hypertensive emergencies require: 1

• ICU admission
• Continuous BP monitoring (arterial line preferred for nitroprusside)
• Continuous cardiac monitoring
• Frequent assessment of target organ function
• Adjustment of infusion rate every 5-15 minutes until target reached

Transition to oral therapy: 4

• Initiate oral antihypertensive upon discontinuation of IV therapy
• If switching to nicardipine capsules TID: Give first oral dose 1 hour before stopping infusion
• For other oral agents: Start immediately upon IV discontinuation