What is the best course of treatment for a confused adult female patient with severely elevated blood pressure (hypertension) and confusion?

Hypertensive Emergency with Altered Mental Status

This patient requires immediate ICU admission and parenteral antihypertensive therapy—this is a hypertensive emergency defined by severely elevated blood pressure (170/110 mmHg) with acute target organ damage (confusion indicating hypertensive encephalopathy). 1

Immediate Assessment (Within Minutes)

Confirm this is a true hypertensive emergency by rapidly assessing for target organ damage:

• Neurologic damage: Altered mental status (present in this patient), headache with vomiting, visual disturbances, seizures, or focal deficits 1, 2
• Cardiac damage: Chest pain, acute MI, pulmonary edema, acute heart failure 1
• Renal damage: Acute kidney injury with elevated creatinine, oliguria 1
• Ophthalmologic damage: Bilateral retinal hemorrhages, cotton wool spots, or papilledema on fundoscopy (malignant hypertension) 1, 2
• Vascular damage: Signs of aortic dissection 1

The presence of confusion with BP 170/110 mmHg indicates hypertensive encephalopathy—the rate of BP rise is more important than the absolute value, and previously normotensive individuals tolerate elevated BP poorly compared to those with chronic hypertension. 1

Essential Laboratory Tests (Obtain Immediately)

• Complete blood count (hemoglobin, platelets) to assess for microangiopathic hemolytic anemia 1
• Basic metabolic panel (creatinine, sodium, potassium) to evaluate renal function and electrolytes 1
• Lactate dehydrogenase (LDH) and haptoglobin to detect hemolysis in thrombotic microangiopathy 1
• Urinalysis for protein and urine sediment to identify renal damage 1
• Troponins if any chest pain present 1
• ECG to assess for cardiac involvement 1

First-Line Treatment

Nicardipine IV is the preferred first-line agent for hypertensive encephalopathy because it maintains cerebral blood flow and does not increase intracranial pressure. 1

Nicardipine Dosing:

• Initial dose: 5 mg/hr IV infusion 1, 3
• Titration: Increase by 2.5 mg/hr every 15 minutes until desired BP reduction 1, 3
• Maximum dose: 15 mg/hr 1, 3
• Preparation: Dilute 25 mg vial with 240 mL compatible IV fluid to achieve 0.1 mg/mL concentration 3
• Administration: Via central line or large peripheral vein; change infusion site every 12 hours if peripheral 3

Alternative First-Line Agent:

Labetalol can be used if nicardipine is unavailable 1

• Initial bolus: 10-20 mg IV over 1-2 minutes 1
• Repeat dosing: Double dose every 10 minutes until target BP achieved 1
• Maximum cumulative dose: 300 mg 1
• Continuous infusion: 2-8 mg/min after initial bolus 1
• Contraindications: Reactive airway disease, COPD, heart block, bradycardia, decompensated heart failure 1

Blood Pressure Target

Reduce mean arterial pressure by 20-25% within the first hour. 1, 2

• First hour: Reduce MAP by 20-25% (or SBP by no more than 25%) 1, 2
• Next 2-6 hours: If stable, reduce to 160/100 mmHg 1, 2
• Next 24-48 hours: Cautiously normalize BP 1, 2

Critical warning: Avoid excessive acute drops >70 mmHg systolic—this precipitates cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation. 1, 2

Monitoring Requirements

• ICU admission (Class I recommendation, Level B-NR) 1, 2
• Continuous arterial line BP monitoring 1
• Serial neurological assessments: Mental status, visual changes, seizures 1
• Continuous cardiac monitoring: Watch for reflex tachycardia with nicardipine 1
• Serial assessment of target organ function 1

Medications to Avoid

Never use these agents in hypertensive encephalopathy:

• Immediate-release nifedipine: Causes unpredictable precipitous BP drops and reflex tachycardia 1, 4
• Hydralazine: Unpredictable response and prolonged duration 1
• Sodium nitroprusside: Use only as last resort due to cyanide toxicity risk; can increase intracranial pressure 1, 4

Post-Stabilization Management

After BP stabilization (typically 24-48 hours):

• Screen for secondary hypertension causes: 20-40% of malignant hypertension cases have identifiable causes (renal artery stenosis, pheochromocytoma, primary aldosteronism) 1, 2
• Address medication non-adherence: The most common trigger for hypertensive emergencies 1
• Transition to oral therapy: Combination of RAS blockers, calcium channel blockers, and diuretics 1
• Target BP: <130/80 mmHg for most patients 1
• Frequent follow-up: At least monthly until target BP reached and organ damage regressed 1

Critical Pitfalls to Avoid

• Do not treat the BP number alone—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 1
• Do not lower BP to "normal" acutely—patients with chronic hypertension have altered cerebral autoregulation and cannot tolerate acute normalization 1, 2
• Do not use oral medications for initial management—hypertensive emergency requires IV therapy 1
• Do not delay ICU transfer—time-to-treatment is critical in hypertensive emergencies 1