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Here is a complete, memory-focused breakdown of this page - Chapter 1: Cardiology - Hypertensive Emergencies (Tables 1.56 & 1.57).

🧠 HYPERTENSIVE EMERGENCIES - Master Sheet

PART 1: Table 1.56 - Condition → Drug → Target → Traps

Use the mnemonic "AAA-SIH" for the 7 conditions: Aortic dissection, Acute pulmonary edema, Acute coronary syndrome, Subarachnoid hemorrhage, Intracranial bleed, (acute renal failure), Hypertensive encephalopathy.

1. Acute Aortic Dissection

Drug: Esmolol/Labetalol + Nitroprusside (combo)
Target: SBP down to 100-110 mmHg ASAP + control tachycardia
Remember:
- Always give β-blocker BEFORE vasodilator (never vasodilator alone - it causes reflex tachycardia which worsens dissection)
- Hydralazine is CONTRAINDICATED (causes reflex tachycardia)
- Avoid volume depletion

Trick: "Before you dissect, block (β-block) first."

2. Acute Pulmonary Edema

Drug: Nitroglycerine infusion (1st line, bold), IV enalaprilat, nitroprusside, IV furosemide
Target: Reduce BP by 20-30%
Trap: Enalaprilat can cause hypotension - be cautious

Trick: "Lungs are wet → NiTroGlycerine takes the fluid out."

3. Acute Coronary Syndrome (ACS)

Drug: Nitroglycerine infusion + β-blockers (metoprolol or labetalol)
Target: Reduce BP by no more than 20-30%
Trap: In right ventricular infarction - beware of hypotension (RV preload dependent!)

Trick: "Heart attack = No more than 20-30% drop, or RV infarct will crash."

4. Acute Renal Failure

Drug: Labetalol IV, Nicardipine infusion, Dialysis
Target: No more than 20-30% BP reduction
Avoid: Nitroprusside (cyanide/thiocyanate toxicity) and ACE inhibitors (worsen renal function)

Trick: "Kidneys hate Nitroprusside & ACE inhibitors."

5. Subarachnoid Hemorrhage (SAH)

Drug: Labetalol bolus/infusion, Esmolol bolus/infusion, Nicardipine infusion (bold = preferred), Nimodipine (DHP calcium blocker - especially to prevent vasospasm)
Target: SBP < 160 mmHg OR MAP < 130 mmHg
Trick: Control pain → helps control BP

Trick: "SAH: Nimodipine = Nimo saves neurons from vasospasm."

6. Intracranial Bleed

Drug: Labetalol infusion, Nitroglycerine infusion
Target: Gradual 20-25% BP reduction
CRITICAL RULE: Never lower BP by more than 10-15% in 24 hours

Trick: "Brain bleed = go slow. 10-15% in 24h - any more and the brain dies."

7. Hypertensive Encephalopathy

Drug: IV Sodium Nitroprusside = DRUG OF CHOICE (rapid onset), also IV labetalol, nicardipine, hydralazine
Target: Reduce mean BP by 20% within the first hour

Trick: "Encephalopathy = Nitroprusside - it works immediately (like turning off a tap)."

PART 2: Table 1.57 - Drug Details (Memory Table)

Quick-Reference: Onset & Duration

Drug	Onset	Duration	Route	Key Feature
Sodium Nitroprusside	Immediate	2-3 min	IV infusion	Fastest onset; shield from light
Fenoldopam	<5 min	30 min	IV infusion	Dopamine agonist
Nitroglycerin	1-5 min	10 min	IV infusion	Headache; tolerance with prolonged use
Esmolol	1-2 min	3-10 min	IV bolus/infusion	Ultra-short acting β-blocker
Phentolamine	1-2 min	3-10 min	IV bolus	α-blocker; for pheochromocytoma
Clevidipine	2-4 min	5-15 min	IV infusion	Newest CCB; double dose q90 sec
Nicardipine	1-5 min	3-6 h	IV infusion	5 mg/h, titrate up to 15 mg/h
Labetalol	5-10 min (bolus)	3-6 h	IV bolus/infusion	α+β blocker
Enalaprilat	5-15 min	1-6 h	IV bolus	ACE inhibitor (IV)
Diazoxide	15 min	6-12 h	IV bolus	Longest acting here
Hydralazine	10-20 min	3-6 h	IV bolus	For eclampsia
Methyldopa	30-60 min	10-16 h	IV bolus	Slowest onset; for eclampsia

Key Adverse Effects to Memorize

Sodium Nitroprusside:

Cyanide toxicity (hepatic failure) + Thiocyanate toxicity (renal failure)
Must shield from light
Avoid in renal/hepatic insufficiency (reduce dose to 0.25 µg/kg/min in eclampsia/renal)

Diazoxide:

Hyperglycemia (opens K+ channels like sulfonylureas in reverse)
Can exacerbate myocardial ischemia, heart failure, aortic dissection

Labetalol:

Scalp tingling (unique side effect - easy to remember!)
Paradoxical pressor response
Ineffective if patient already on α- or β-antagonists

Hydralazine:

For eclampsia only in this context
Change infusion site after 12 hours (local thrombophlebitis)
Fetal distress possible

Methyldopa:

Slowest onset (30-60 min) - used in eclampsia
Simple side effect: Hypotension

Nitroglycerin:

Tolerance develops with prolonged use
Headache (classic)

Phentolamine:

Paradoxical pressor response
Think: pheochromocytoma crisis

PART 3: High-Yield Memory Tricks

"Which drug is DRUG OF CHOICE?"

Hypertensive encephalopathy → IV Sodium Nitroprusside

"Which drugs are CONTRAINDICATED where?"

Situation	Avoid
Aortic dissection	Hydralazine
Acute renal failure	Nitroprusside + ACE inhibitors
RV infarction	Avoid BP drop (hypotension)

"Eclampsia drugs" (only 2):

Hydralazine (10-20 mg q 20 min) - 1st line
Methyldopa (250-500 mg) - backup

"Vasospasm after SAH":

Nimodipine = only drug specifically for this (DHP CCB, oral usually but listed here)

"Fastest drugs" (useful for exams):

Immediate: Nitroprusside
Near-immediate: Esmolol, Phentolamine (1-2 min)
Slowest: Methyldopa (30-60 min)

"Longest duration":

Methyldopa (10-16 h) > Diazoxide (6-12 h) > Labetalol/Hydralazine/Nicardipine (3-6 h)

PART 4: Dosage Anchors (High-Yield Numbers)

Drug	Anchor Dose
Nitroprusside	0.5-10 µg/kg/min (start 0.25 in eclampsia/renal failure)
Labetalol (bolus)	20-80 mg q5-10 min, max 300 mg
Diazoxide	50-100 mg q5-10 min, max 600 mg
Esmolol	Loading: 500 µg/kg/min x 1 min, then 50-300 µg/kg/min
Hydralazine	10-20 mg q20 min
Nicardipine	5 mg/h → max 15 mg/h
Clevidipine	1-2 mg/h, double q90 sec, max 16 mg/h
Nitroglycerin	5-250 µg/min

ONE-LINE SUMMARY STORY

"A patient with aortic Dissection needs β-block first then dilate (never Hydralazine). Pulmonary edema? NTG. ACS? NTG + β-blocker (watch RV infarct). Renal failure? No nitroprusside, no ACE. SAH? Nimodipine for vasospasm. Brain bleed? Go slow (<10-15% in 24h). Hypertensive encephalopathy? Nitroprusside STAT, 20% in 1 hour."

This covers every clinically testable point on the page. Review the one-line summary daily for 3 days and the tables will stick permanently.

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