Principles of management

1. Adequate monitoring (invasive BP, ECG, CVP, CO, urine output)

2. Consider pain, hypovolaemia, hypothermia and agitation, especially if paralysed.

3. Consider specific treatment for, e.g. phaeochromocytoma, thyroid crisis, aortic dissection, inflammatory vasculitis

4. Slow intravenous infusion of nitrate or nitroprusside. GTN is usually given first before considering sodium nitroprusside. Other options include labetalol or esmolol infusions, and hydralazine (IV or IM). Sublingual nifedipine or IV hydralazine may sometimes produce precipitate falls in BP. Use cautiously and start with low doses.

5. Aim to reduce to mildly hypertensive levels unless a dissecting aneurysm is present where systolic BP should be lowered <100-110mmHg. After certain types of surgery (e.g. cardiac, aortic), control of systolic blood pressure <100-120mmHg may be requested to reduce risk of bleeding.

6. Longer term treatment, e.g. an oral ACE inhibitor, should be instituted with caution, starting at low doses.

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