Hypertensive EmergencyICU / resuscitation

BP 240/130 with blurred vision, pulmonary oedema and creatinine climbing — the DAMAGE defines the emergency, not the number. Lower SBP by no more than 25% in the first hour.

• Headache + confusion/seizures
• Chest pain or pulmonary oedema
• Oliguria with rising creatinine
• Retinal haemorrhages/papilloedema

• Pain/anxiety-driven surge
• Recreational sympathomimetics (cocaine, amphetamine)
• Pheochromocytoma
• Medication non-adherence rebound (clonidine)

• ICU: Any acute target-organ damage
• MAP drop: SBP ≤25% in the first hour — never to 'normal' acutely
• Stroke exception: Treat only >220/120 (>185/110 pre-lytic)

• The number never defines the emergency — encephalopathy, APE, ACS, AKI or retinopathy does
• Clevidipine is the smoothest titratable agent (short half-life, lipid emulsion)
• Always hunt the secondary cause later: renal artery, pheochromocytoma, primary aldosteronism

• Drop BP to normal in the first hours — cerebral hypoperfusion and watershed infarction
• Use sublingual nifedipine — precipitous uncontrolled drops
• Give IV drips or intermittent agents for severe hypertension without organ damage (asymptomatic) — no acute lowering at all is recommended; oral therapy and observation suffice (2025 AHA/ACC)

• Over-correction → new neurological deficit
• Treating urgency with ICU drips
• Forgetting eclampsia in pregnancy
• No secondary workup before discharge
• ICH nuance: target SBP 130–<140 for presenting SBP 150–220 (2025 AHA/ACC)

ICU until on stable oral regimen; investigate secondary causes (renal ultrasound, aldosterone:renin, metanephrines); BP clinic within 1 week.