High blood pressure without end organ damage is NOT<unk>  (see asymptomatic hypertension)
Goal: Lower mean arterial or systolic pressure by no more than 10-20% in the first hour
Then lower by an additional 5-15% over the next 23 hours for no more than 25% in the first 24 hours
Exception is aortic dissection which requires rapid reduction to systolic BP to 100-120 mmHg
Be careful of lowering BP in patients with CVA
Then lower by an additional 5-15% over the next 23 hours for no more than 25% in the first 24 hours
Exception is aortic dissection which requires rapid reduction to systolic BP to 100-120 mmHg
0.3-0.5 mcg/kg/min IV initial infusion
Increase by 0.5 mcg/kg/min up to 2mcg/kg/min

1. Very effective
2. Immediate onset/offset
1. Cyanide Toxicity
2. Coronary steal?
3. Increased HR
1. Avoid in liver/renal failure
2. Avoid with increased ICP
3. Avoid in pregnancy
1. Rapid on/offset
2. Increases coronary flow
Drug of choice in patients with cardiac ischemia,
LV dysfunction, or pulmonary edema
20-80mg IV bolus q10 min OR
0.5-2 mg/min IV infusion or
200mg to 400mg PO BID
1. No change in HR, cerebral flow
2. Rapid onset
Avoid in COPD, CHF and heart block
1. Consider in ACS
2. Consider in ischemic CVA
Load 250-500 mcg/kg over 2min
Infuse 50 mcg/kg/min over 4min
- if ineffective repeat load, increase infusion rate by  50mcg/kg/min up to 300mcg/kg/min
Avoid in COPD, CHF
bradycardia
Consider in ACS
Start 5mg/h
If ineffective after 15min increased in 2.5mg/hr interval up to 15mg/hr
5-15mg IV bolus q5-15min OR
0.2-0.5mg/min IV infusion
1. Used in patients at risk for cerebral hypotension, CHF
2. Avoid in pregnancy
0.1 - 0.3 mg PO q12 scheduled; For<unk> , 0.2 mg x1, then 0.1 mg q1 hr PRN, max 0.6 mg total

10 - 20 mg slow IV/IM bolus q4-6 hr PRN, max 40 mg/dose

Rapidly reduce sys BP to 100-120; HR 60-80 within 20min
Adequate analgesia will decrease sympathetic drive and assist with BP and HR control
Avoid volume depletion
Prevent reflex tachycardia
Labetalol alone
Nitroprusside or nicardipine AFTER metoprolol or esmolol
Labetalol alone
Nitroprusside or nicardipine AFTER metoprolol or esmolol
Reduce BP by 20-30%
Promote diuresis AFTER vasodilation
No more than 20-30% reduction for SBP >160
Consider NTG, beta-blocker
Benzos
Mixed α + B blockade
Phentolamine OR nitroprusside AND β-blocker
Phentolamine OR nitroprusside AND β-blocker
Reduce BP by no more than 20%
Avoid nitroprusside (renal metabolism)
Labetalol or nicardipine
Goal BP <160/110
Labetalol or nicardipine
Magnesium
Decrease MAP by 15-20%
Avoid overly aggressive lowering
Nicardipine or labetalol
Avoid overly aggressive lowering
SAH
See Subarachnoid Hemorrhage (SAH)
ICH
See current guidelines for best practice
Labetalol or Nicardipine or Esmolol
Ischemic
If thrombolytic treatment is planned then goal systolic blood pressure 185 mm Hg and diastolic blood pressure 110 mm Hg
If no thrombolytics then consider blood pressure control if SBP >220 mmHg or DBP >120 mmgHg
Labetalol or Nicardipine are both effective and safe
See Subarachnoid Hemorrhage (SAH)
Labetalol or Nicardipine or Esmolol
If thrombolytic treatment is planned then goal systolic blood pressure 185 mm Hg and diastolic blood pressure 110 mm Hg
If no thrombolytics then consider blood pressure control if SBP >220 mmHg or DBP >120 mmgHg
Labetalol or Nicardipine are both effective and safe
Phentolamine OR (nitroprusside AND β-blocker)
Hypertensive emergency
Hypertensive urgency
Stroke
Subarachnoid hemorrhage
Sympathetic crashing acute pulmonary edema
Idiopathic intracranial hypertension
Ischemic stroke
Traumatic hyphema