Synopsis
Separate acute severe blood pressure without organ injury from accelerated hypertension and true emergency, investigate target-organ damage and lower pressure at the right speed.
- Accelerated (malignant) hypertension is BP at least 180/120 mmHg with retinal haemorrhage and/or papilloedema.
- A hypertensive emergency is severe BP elevation with acute, ongoing target-organ injury—not a number alone.
- Same-day referral is required for BP at least 180/120 with retinal changes or life-threatening neurological, cardiac, aortic or renal features.
Key red flags
BP at least 180/120 mmHg plus retinal haemorrhage and/or papilloedema; often accompanied by headache, visual symptoms, renal injury or microangiopathy.
Investigation priorities
Confirm severe BP, identify inter-arm clues and diagnose accelerated retinal injury.
Management branches
BP at least 180/120 plus retinal haemorrhage/papilloedema or life-threatening neurological, cardiac, aortic or renal features.
- First: repeat accurate BP while beginning ABC, neurological, cardiac, volume and fundal assessment; obtain IV access and monitoring.
- Next: refer/admit same day to the appropriate acute team and investigate the organ syndrome in parallel.
Key medicines
Labetalol IV50 mg IV over 1 minute; repeat at 5-minute intervals if needed to a total maximum 200 mg. Alternatively infuse a 1 mg/mL solution, commonly around 160 mg/hour titrated to response.
Nicardipine IVStart 3–5 mg/hour by continuous IV infusion for 15 minutes, increase by 0.5–1 mg/hour every 15 minutes to response; maximum 15 mg/hour, then reduce to about 2–4 mg/hour maintenance.