20th June 2026

Specific emergencies

Malignant hypertension

     Malignant hypertension is a subcategory of hypertensive emergency, which includes either grade III or IV retinopathy. Hypertensive encephalopathy refers to neurological symptoms caused by severely elevated blood pressure and typically improves with blood pressure correction. Intracranial haemorrhage may occur with malignant hypertension.

Management:

• 1st line – Labetalol infusion
• 2nd line – Nicardipine or nitroprusside if no evidence of raised intracranial pressure
• 3rd line – Fenoldopam

Aim to reduce mean arterial pressure by 20-25% within the first 2-4 hours, then to 160/100-110 mmHg within the next 2-6 hours [2].

Myocardial Ischaemia or Infarction

Management:

1. 1st line – Esmolol + GTN infusion
2. 2nd line – Labetalol + GTN infusion

Heart failure / pulmonary oedema

IV nitroglycerin or nitroprusside may be considered as an adjuvant to diuretic therapy. Due to the potential of significant hypotension, nitroprusside should be used with invasive haemodynamic monitoring, typically in the intensive care setting.

Aortic Dissection

Aortic dissection requires particularly aggressive blood pressure management to reduce the risk of propagation of the dissection.

Aortic dissection is classified based on its location and duration:

1. Stanford Classification: 
   • Type A: Involves the ascending aorta, with or without the involvement of the aortic arch and descending aorta
   • Type B: Involves only the descending aorta
2. DeBakey Classification: 
   • Type I: Originates in ascending aorta, propagates at least to the aortic arch
   • Type II: Originates in and is confined to the ascending aorta
   • Type III: Originates in descending aorta, extends distally or proximally

Management:

1. 1st line – Combination of IV beta-blocker (e.g., labetalol or esmolol) and vasodilator (e.g., nicardipine or nitroprusside)
2. If using labetalol alone, higher doses may be required

Targets:

• Reduce systolic BP to <120 mmHg within the first hour of presentation
• Maintain systolic BP < 120 mmHg or to the lowest BP that maintains adequate end-organ perfusion
• Target heart rate of 60 to 80 bpm

Definitive treatment depends on the type of dissection: 

• Type A typically requires urgent surgical intervention
• Uncomplicated Type B can often be managed medically, with endovascular repair considered in certain cases

Remember, in all cases, the key principle is to lower blood pressure gradually to avoid organ hypoperfusion, while being mindful of the specific risks associated with each condition.