cardio.hypertensive-emergency.encephalopathy.v1

Hypertensive encephalopathy (HTN crisis with cerebral edema / AMS / papilledema)

cardiologyacuteadultacuteinpatienttransitionoutpatient

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Phase E variant of cardio.hypertensive-emergency.core.v1 — narrowed to hypertensive encephalopathy phenotype (cerebral edema, AMS, papilledema, severe HA, vision change) without focal deficit. Inherits HTN-emergency framework + workup arc from parent; specializes for autoregulation-aware drug + monitoring profile (nicardipine first-line; AVOID nitroprusside/hydralazine/nimodipine; MAP ↓ ≤25% in 1 h; SBP <140-160 within 6 h; q15-30 min neuro exam during titration). Manifest pointer reuses cardio.hypertensive-emergency.core.v1 manifest. Design-brief pointer reuses parent (encephalopathy-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as part of HTN emergency Phase E variant batch.

Entry points (3)

vital_abnormality
SBP >180 + AMS / severe headache / papilledema / vision change WITHOUT focal deficit (ACC/AHA 2025 HTN; Vaughan Lancet 2000 PMID 10972386)
sbp_gt_180_with_ams_or_severe_ha
symptom
Funduscopy showing papilledema / hemorrhages / exudates (Keith-Wagner-Barker grade III/IV)
papilledema_or_keith_wagner_grade_iii_iv
imaging
MRI showing posterior reversible encephalopathy syndrome (PRES) / parieto-occipital edema pattern (Vaughan Lancet 2000 PMID 10972386)
mri_pres_pattern

Required inputs (9)

agerequired
demographic • used at CONTEXT
Older patients have rightward-shifted cerebral autoregulation curve — precipitous BP drop risks ischemia (ACC/AHA 2025; Vaughan Lancet 2000)
sbprequired
vital • used at RED_FLAGS
Defines crisis threshold (≥180) + drives autoregulation-aware titration (MAP ↓ ≤25% in 1 h; SBP <140-160 within 6 h)
dbprequired
vital • used at RED_FLAGS
Component of MAP calculation; DBP >120 supports emergency criterion
gcsrequired
vital • used at MONITORING
GCS trend during titration — rapid decline with BP drop signals overshoot through autoregulation floor
neuro_exam_focal_deficit_screenrequired
symptom • used at RED_FLAGS
Focal deficit excludes hypertensive encephalopathy → routes to ICH or ischemic stroke pathway instead
fundus_keith_wagner_graderequired
symptom • used at INITIAL_WORKUP
Papilledema / KWB grade III-IV supports diagnosis + tracks treatment response
ct_head_nonconrequired
imaging • used at INITIAL_WORKUP
Rule out ICH (mandatory before BP titration) + parieto-occipital edema pattern of PRES
mri_brain_pres_pattern
imaging • used at BRANCHING_WORKUP
Posterior reversible encephalopathy syndrome pattern confirms diagnosis when CT non-diagnostic (Vaughan Lancet 2000 PMID 10972386)
creatininerequired
lab • used at INITIAL_WORKUP
AKI co-presence drives nicardipine-over-nitroprusside selection (cyanide risk eGFR <30)

12-phase flow (10)

1FRAME
Hypertensive encephalopathy = severe HTN + cerebral edema features (AMS, papilledema, severe HA, vision change) WITHOUT focal deficit; cerebral autoregulation curve is right-shifted in chronic HTN — precipitous drop risks ischemia. Distinguish from ICH (focal deficit) and ischemic stroke (focal deficit). Route to parent engine for shared HTN-emergency arc; this dossier owns the autoregulation-aware drug + monitoring profile.
inputs: sbp, dbp, neuro_exam_focal_deficit_screen
advance: encephalopathy phenotype confirmed + ICH/stroke ruled out on CT
2ENTRY
Recognize SBP >180 + AMS / severe HA / papilledema; obtain CT head FIRST to exclude ICH before BP drop
inputs: age, sbp
advance: CT head obtained
3CONTEXT
Chronic HTN duration (autoregulation shift), antihypertensive history, secondary causes (cocaine, eclampsia, immunosuppressant in PRES)
inputs: age
advance: context complete
4RED_FLAGS
Coma / GCS <8 → intubation + tighter target; new focal deficit → re-image, switch to ICH/stroke pathway; status epilepticus → benzo + AED
inputs: sbp, gcs, neuro_exam_focal_deficit_screen
actions: htn_emergency
advance: RED flags screened + airway plan documented
5INITIAL_WORKUP
BMP, troponin, ECG, CT head non-con (mandatory), funduscopy with KWB grading, β-hCG if reproductive-age (rule out eclampsia overlap)
inputs: creatinine, ct_head_noncon, fundus_keith_wagner_grade
actions: panel.cardiac, panel.renal
advance: workup documented + ICH excluded
6BRANCHING_WORKUP
MRI brain if CT non-diagnostic + PRES suspected (parieto-occipital edema); LP only if meningitis/SAH suspected; toxicology if sympathomimetic context
inputs: mri_brain_pres_pattern
advance: PRES/encephalopathy pattern confirmed or alternative dx identified
7TREATMENT
Nicardipine IV first-line (predictable cerebral autoregulation effect; titratable; no CSF/ICP issues). Goal: MAP ↓ ≤25% in first hour; SBP <140-160 within 6 h. AVOID precipitous drop — risk of ischemic conversion through right-shifted autoregulation floor. Clevidipine alternative. Labetalol second-line if tachycardia. AVOID nitroprusside (cyanide; may worsen ICP), hydralazine (unpredictable BP drop), nimodipine (SAH-only indication).
inputs: sbp, dbp, creatinine
advance: IV agent titrated to syndrome-specific target with neuro exam preserved
8DISPOSITION
ICU mandatory for q5-15 min BP + q15 min neuro exam; arterial line; intubation if GCS <8
advance: ICU bed assigned
9MONITORING
Arterial line + q5-15 min BP; q15-30 min neuro exam during first 6 h; daily fundus exam; daily BMP for AKI; serial troponin if elevated; MRI follow-up to confirm PRES resolution
inputs: sbp, gcs
actions: panel.renal
advance: BP at target × 24 h on IV with neuro improvement
10FOLLOWUP
Transition to oral 4-tier ladder once stable × 6-12 h; 1-week neuro + cardiology + ophthalmology follow-up; MRI at 4-6 wk to confirm PRES resolution; secondary cause workup
advance: oral regimen stable + outpatient follow-up booked