# What was happening with my pt? hypertensive crises? why?



## jshal (Aug 30, 2016)

I get called to a routine minor MVA. The car was rear ended at a red light. Fire on scene. 1 pt, 40 y/o F,  wearing a seat belt, c/o headache, neck and back pain. denies dizziness, LOC, or striking her head on anything, PEARL ,- SOB, - Bleeding/swelling, + PMS x 4 Extremities. Says she wants to RMA and wait for the cops. I gave her the whole routine, and ended up saying, "alright, but let me just get a set of vitals before I go" 

220/140!  
HR102, Normal Resp. no history of HTN, no cardiac history, the list of negatives go on...pretty much a clean bill of health. does not seem to be under the influence of any drugs. I tell her she should come with us because of her blood pressure. she says no. I take the pressure again on the other arm. 218/142. I tell her about what could happen to her with such a high BP. still wants to RMA. very adamant about it. She signs. 

what could cause her BP to shoot up like this? was it just excitement? was there some kind of trauma I missed? was she lying to me about her history? 

thoughts?


----------



## Qulevrius (Aug 30, 2016)

Stressed, overweight, in pain, overcaffeinated, heavy smoker, hyperthyroidism, ESRD who hadn't dialised, sleeping disorder... The list goes on, take a pick.


----------



## jshal (Aug 30, 2016)

esrd makes sense but she denied anything like that. Im new, are you saying stress and pain can cause 220 systolic? do you see it alot?


----------



## Qulevrius (Aug 30, 2016)

All what I listed are contributing factors. It could be either of them, or a combination of some. You do not have the diagnostic equipment to determine the cause, nor you're required to do it. Your job is to make a decision whether her condition is life threatening and then either to treat the pt within the confinement of your scope and transport to an appropriate facility, or AMA them.

Yes, I've seen a few pts with abnormally high bp who haven't had any other life threatening symptoms.  It's always circumstantial.


----------



## jshal (Aug 30, 2016)

ok. just curious. thanks.


----------



## ERDoc (Aug 30, 2016)

It has probably been that high for months but she hasn't had it checked.  She needs to see her PMD.


----------



## zzyzx (Aug 31, 2016)

This is actually a situation where an EMT can make a big difference in a patient's life.
EMT's (and nurses) freak out when they see a very high BP. The important thing to understand is that this is not an emergency and no, you don't need to talk them into going to the ER because that will be a waste of time and resources for both the patient and the ER staff.
What the patient does need to understand is that they need to see their doctor as soon as possible in order 1) confirm that they have hypertension  2) get on medication and diet/lifestyle adjustments.
The problem of course is that many people don't have a PMD or even if they do, they would rather be in denial of the fact that they have a medical problem. Telling them that they could in the future have a stroke or heart problems, but from my experience what really gets their attention is when you tell them that they could develop kidney failure and end up going to dialysis three times a week. Taking a few minutes to talk to them and really drive home the point that they need to follow up with a doctor can make a positive impact in their lives.


----------



## Akulahawk (Aug 31, 2016)

zzyzx said:


> This is actually a situation where an EMT can make a big difference in a patient's life.
> EMT's (and nurses) freak out when they see a very high BP. The important thing to understand is that this is not an emergency and no, you don't need to talk them into going to the ER because that will be a waste of time and resources for both the patient and the ER staff.
> What the patient does need to understand is that they need to see their doctor as soon as possible in order 1) confirm that they have hypertension  2) get on medication and diet/lifestyle adjustments.
> The problem of course is that many people don't have a PMD or even if they do, they would rather be in denial of the fact that they have a medical problem. Telling them that they could in the future have a stroke or heart problems, but from my experience what really gets their attention is when you tell them that they could develop kidney failure and end up going to dialysis three times a week. Taking a few minutes to talk to them and really drive home the point that they need to follow up with a doctor can make a positive impact in their lives.


Most nurses and EMTs freak out when they see a very high BP. With good reason... but the key thing to remember is to ask about symptoms. The hypertensive patient that's asymptomatic probably doesn't need an immediate workup for HTN... they just need a visit to their Primary Care Provider. Most of the time in my ED when I get a patient that is hypertensive, I'll ask them if they know about the issue and ask them about symptoms. If there aren't any symptoms, I'll let the Doc know (mostly for CYA purposes) and that the patient is asymptomatic. I'll do some education about needing to see their Primary Care soon to start getting the blood pressure under control but... that's about it. Most of the time some education and an urging to see primary care is all we do for the "generic" HTN patient.


----------



## CALEMT (Aug 31, 2016)

She was just in a car crash. Not saying that her b/p will be normal but it's expected to be high.


----------



## Arovetli (Sep 5, 2016)

It's a very sad reality, but 200's systolic/100's diastolic are "normal" for an awful lot of people...as other posters mentioned, a lot of literature out now showing, from an emergency/urgent care standpoint, not much indication to treat. I always try and educate the patients on their BP and hope if 1,000 healthcare providers nag them about it, they'll treat it before their organs shut down.


----------



## BobBarker (Sep 6, 2016)

Although we all probably know that the neck, head and back pain are because of the impact, this would qualify as a "hypertensive emergency" according to the America Heart Association(http://www.heart.org/HEARTORG/Condi...ve-Crisis_UCM_301782_Article.jsp#.V856FpMrJPM).

Any BP of 180 Systolic or 120 Dyastolic(she was high on both) and symptoms such as blurred vision, back pain, numbness/weakness or chest pain should seek immediate attention. To the OP: You did everything you could but she didn't want to go. Educating her on seeing her primary doctor or a doctor very soon would is good also. To be honest, I don't think her BP was caused just because of the accident, seems way too high for it to be just that. My father has ESRD and hypertension, and the last time I saw him extremely upset and yelling, his BP went up to 182/98. She probably has undetected/untreated hypertension.


----------

