# Treating Hypertension



## tchristifulli (Oct 15, 2013)

So a recent discussion has me thinking a bit. 48 yr male patient who states he has a tearing sensation in his chest. Bp 200/111, Hr 100,RR 22. EKG is normal. You suspect an aortic dissection. You are on an ALS rig. Would you treat the hypertension?


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## DrankTheKoolaid (Oct 15, 2013)

I would treat the chest pain which in turn would lower the BP. If i was thinking cardiac NTG , ms. If I was thinking dissection as much morphine as bp would allow


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## Handsome Robb (Oct 15, 2013)

What do you plan on using to treat it?

I wouldn't give this patient NTG. If they are dissecting the potential rebound HTN could be the straw that broke the camel's back. 

How far from the ER are we? Is that hospital capable of providing definitive care or is there a facility that's a bit further but is capable that you're allowed to transport to? 

If we're far enough out that I feel forced to address it I want labetelol. The alpha antagonistic effects plus the negative chronotropic effects are what I want.


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## TransportJockey (Oct 15, 2013)

With my current protocols i would give morphine to 20mg and see how they do.


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## tchristifulli (Oct 15, 2013)

Would you be concerned that vasodilation would make the dissection worse?


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## TransportJockey (Oct 15, 2013)

tchristifulli said:


> Would you be concerned that vasodilation would make the dissection worse?



Slightly yes, but in small doses over time not so much. Or I could just go with up to 3mcg/kg fent. I have a long enough transport time I can titrate both to pressure and pain levels.


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## tchristifulli (Oct 15, 2013)

Your purpose in fentanyl is just to take away the pain?


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## STXmedic (Oct 15, 2013)

tchristifulli said:


> Your purpose in fentanyl is just to take away the pain?



The anxiolytic effect of fentanyl would be beneficial, as well. I'd personally use morphine as my initial choice, though.


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## VFlutter (Oct 15, 2013)

Unless you have beta blockers, preferably labetalol, I would not primarily treat the hypertension. I would avoid NTG. Then max out your pain management and sedation as allowed.


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## TransportJockey (Oct 15, 2013)

tchristifulli said:


> Your purpose in fentanyl is just to take away the pain?



Anxiolytic, pain control, and reduced MVO2, primarily. I don't carry any antihypertensives, so I can do my best to help the body control itself all on it's own.



STXmedic said:


> The anxiolytic effect of fentanyl would be beneficial, as well. I'd personally use morphine as my initial choice, though.



With a pressure like that, MS would most likely be my first choice as well.


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## Rialaigh (Oct 15, 2013)

mmm I am going to treat the pain but have no plans for BP reduction other then what pain control alleviates. A bp of 200/111 in the presence of suspected aortic dissection is bad but with transport times for me of always less than an hour I really can't think of any circumstances in which I am going to try and control BP at all in the field.

 There are some great articles and podcasts out there on the difference between hypertensive emergency and hypertensive urgency. The progressive ER physicians are sending people home with BP's of 260/140 because there are no signs of end organ failure and frankly that BP is not an acute event, it's a chronic problem that is solved by careful dosing of multiple oral anti-hypertensives. 

I can almost assure you that there is no difference in mortality and morbidity for any condition which is treated or not treated pre-hospital for hypertension. (all other factors equal). I just see no evidence (thus far) that shows any indication for prehospital treatment of hypertension. Now if you want to talk extended IFT transports than that is a different ball game.


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## Handsome Robb (Oct 15, 2013)

tchristifulli said:


> Would you be concerned that vasodilation would make the dissection worse?



Yes but at 200/111 I'm worried about rupturing that aorta and watching him die on my cot with nothing I can do to stop it.


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## Carlos Danger (Oct 15, 2013)

The whole goal of therapy in a dissecting aneurysm is reduction of aortic wall tension, which requires reduction of both HR and MAP. 

Analgesia alone is likely not enough, though fentanyl in large enough doses is a good sympatholytic.  

Labetolol is an OK choice. Esmolol is better, IMO. Nitrates are fine but are usually given with a beta blocker in order to reduce chronotropy.

There are different protocols out there, but a common goal is an SBP of 120 or less and a HR 60-70.

I once transported a patient with a dissection who had been intubated so that he could go on a propofol drip because of intractable pain and hypertension. I don't remember what all they tried before the propofol, but he was on a large dose of it as well as nitrates and beta blockers.


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## Handsome Robb (Oct 15, 2013)

Halothane said:


> The whole goal of therapy in a dissecting aneurysm is reduction of aortic wall tension, which requires reduction of both HR and MAP.
> 
> Analgesia alone is likely not enough, though fentanyl in large enough doses is a good sympatholytic.
> 
> ...



Now I've gotta go read a bunch about esmolol and try and figure out why you prefer it....thanks  

Didn't really think of nitrates in combination with beta blockers, definitely makes sense. Would you be alright with sublingual? I'd think the rapid dilation and constriction could make things worse...NTG drip makes sense.


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## Carlos Danger (Oct 15, 2013)

Robb said:


> Now I've gotta go read a bunch about esmolol and try and figure out why you prefer it....thanks
> 
> Didn't really think of nitrates in combination with beta blockers, definitely makes sense. Would you be alright with sublingual? I'd think the rapid dilation and constriction could make things worse...NTG drip makes sense.



It's a really good drug to know. You'll probably see it a fair amount in CCT and flight. 

Esmolol vs. labetolol is just my personal preference....I just think esmolol is easier to use and more predictable (I also like metoprolol better than labetolol for the same reasons; again, just based on my experience). Both are pretty good at dropping BP & HR. I'm not aware of any evidence that esmolol is a better drug for this purpose. At the end of the day, I think any drug or combination of drugs that brings both arterial pressure and HR down to the low-normal range is a good thing in these patients, and there are numerous drugs that can do that.

As far as ntg drip vs. SL, obviously a drip gives you more consistent and titratable effects, but I would think in a patient with high BP who you really suspected of having a dissection, SL ntg would be better than not treating at all. Of course things like severity and transport times and other co-morbidities come into play, as well.


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## medicsb (Oct 16, 2013)

FYI, the aorta does not dilate and constrict beyond the recoil produced with each stroke volume.  The diameter of the aorta will not get bigger with vasodilation.

Nitrates are not preferred, but they can be used.  And it is the hypertension that is most dangerous with aortic dissection, so reducing it directly will be better than trying through indirect means (e.g. pain control).


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## Handsome Robb (Oct 16, 2013)

medicsb said:


> FYI, the aorta does not dilate and constrict beyond the recoil produced with each stroke volume.  The diameter of the aorta will not get bigger with vasodilation.
> 
> Nitrates are not preferred, but they can be used.  And it is the hypertension that is most dangerous with aortic dissection, so reducing it directly will be better than trying through indirect means (e.g. pain control).



Learn something new every day. Thank you!!

I will ask would the potential rapid changes in afterload both reducing and increasing cause any concern? I guess the dissection has a similar pressure change going between systole and diastole though...


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## mycrofft (Oct 17, 2013)

Another concern: this person is going straight to surgery, maybe a quick ultrasound at the receiving door. What do your surgeon and anesthesiologist want? Be a bummer to get the pt there with vital signs, but the op fails because of pharmacy or spoiled venous access.

Any protocols ought to include the receiving facilities' input, and once adopted all receiving facilities need to know what they will receive..then prehospital techs need to _*follow them*_.

I didn't think a vasodilator would directly change a central major vessel, they are actually vaso-_relaxers_, right? Major vessels don't experience the neuro-muscular vasoconstriction peripheral vessels do. Plus in us old calcified specimens, they're pretty non-flexible to begin with.


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## tchristifulli (Oct 18, 2013)

medicsb said:


> FYI, the aorta does not dilate and constrict beyond the recoil produced with each stroke volume.  The diameter of the aorta will not get bigger with vasodilation.
> 
> Nitrates are not preferred, but they can be used.  And it is the hypertension that is most dangerous with aortic dissection, so reducing it directly will be better than trying through indirect means (e.g. pain control).



Where can I find information on the Aorta not responding to vasodilators?


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## STXmedic (Oct 19, 2013)

Physiology textbooks


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## Akulahawk (Oct 19, 2013)

mycrofft said:


> Another concern: this person is going straight to surgery, maybe a quick ultrasound at the receiving door. What do your surgeon and anesthesiologist want? Be a bummer to get the pt there with vital signs, but the op fails because of pharmacy or spoiled venous access.
> 
> Any protocols ought to include the receiving facilities' input, and once adopted all receiving facilities need to know what they will receive..then prehospital techs need to _*follow them*_.
> 
> I didn't think a vasodilator would directly change a central major vessel, they are actually vaso-_relaxers_, right? Major vessels don't experience the neuro-muscular vasoconstriction peripheral vessels do. Plus in us old calcified specimens, they're pretty non-flexible to begin with.


Mycrofft... you're a dinosaur, not a fossil...  You're not quite_ that_ calcified. 

Anyway, something like this could simply be a protocol to contact the BHP and get a destination and treatment orders and have the various receiving facilities come up with what they want done in the field for initial treatment of a dissecting aorta, and what they'd like done to expedite the patient to the OR. 

While such a protocol may have a "mother may I" feel to it, that would also allow the receiving facilities to try different field care ideas in a more flexible manner while allowing for consistency.


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## Wheel (Oct 19, 2013)

Akulahawk said:


> Mycrofft... you're a dinosaur, not a fossil...  You're not quite_ that_ calcified.
> 
> Anyway, something like this could simply be a protocol to contact the BHP and get a destination and treatment orders and have the various receiving facilities come up with what they want done in the field for initial treatment of a dissecting aorta, and what they'd like done to expedite the patient to the OR.
> 
> While such a protocol may have a "mother may I" feel to it, that would also allow the receiving facilities to try different field care ideas in a more flexible manner while allowing for consistency.



I would certainly contact a doc with this, present my findings and concerns along with a proposed treatment plan (nitro tabs and paste and narcs would be my only options.) Then we make a plan and go for it, and I advise of any changes in patient condition. I don't want to cowboy a situation like this when I can consult with the person who will be taking over care of this patient after my short ride with them.

That's not to say be a cookbook medic and pawn the decision off to a doc. This is a great opportunity to be a patient advocate and prove to your receiving facility that you aren't a moron.


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## mycrofft (Oct 19, 2013)

Addressing the aneurysm before it dissects (Oxford Journal): 

http://cardiovascres.oxfordjournals.org/content/83/3/436.long

http://cardiovascres.oxfordjournals.org/content/83/3/436/F1.medium.gif

MEDSCAPE ARTICLE (prehospital dissecting aoritc aneuryms or DAA):

http://emedicine.medscape.com/article/756835-overview#aw2aab6b3

MEDSCAPE defintive tx:   http://emedicine.medscape.com/article/756835-overview#aw2aab6b4

AND I QUOTE:  "Long-term medical therapy involves a beta-adrenergic blocker combined with other antihypertensive medications. Avoid antihypertensives (eg, hydralazine, minoxidil) that produce a hyperdynamic response that would increase dP/dt (ie, alter the duration of P or T waves)".

EMED:

http://www.fjac.com/links/aorticdissection/eMedicineDissectionAortic.htm

AND I QUOTE:  Nitroprusside (Nitropress) -- Causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. Commonly used IV because of rapid onset and short duration of action. Easily titratable to reach desired effect. Light sensitive; both bottle and tubing should be wrapped in aluminum foil. Prior to initiating nitroprusside, administer beta-blocker to counteract physiologic response of reflex tachycardia that occurs when nitroprusside used alone. This physiologic response will increase shear forces against aortic wall, thus increasing dP/dT. Objective is to keep heart rate at 60-80 bpm".

Last, medicines and DAA:

http://cdn.intechopen.com/pdfs/1691...aortic_aneurysms_ruptures_and_dissections.pdf


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## jwk (Oct 20, 2013)

TransportJockey said:


> Anxiolytic, pain control, and reduced MVO2, primarily. *I don't carry any antihypertensives*, so I can do my best to help the body control itself all on it's own.
> 
> 
> 
> With a pressure like that, MS would most likely be my first choice as well.



No antihypertensives available?  That seems strange.  I would have thought that would be pretty standard.  We carried them 30 years ago.


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## jwk (Oct 20, 2013)

Halothane said:


> The whole goal of therapy in a dissecting aneurysm is reduction of aortic wall tension, which requires reduction of both HR and MAP.
> 
> Analgesia alone is likely not enough, though fentanyl in large enough doses is a good sympatholytic.
> 
> ...



To me, esmolol is a lot like labetalol with a much shorter duration of action.  Titrate the doses and it's hard to get into trouble.

Labetalol is a great drug, but easy to overshoot the effect you're looking for if you start out with big doses.

Metoprolol is OK, but the onset is somewhat longer and once it's in, it's not wearing off any time soon.  

Analgesia is fine - but may not help in this situation.

Propofol is not used as an antihypertensive, although it will certainly knock down a blood pressure, particularly with a bolus dose.  A non-sedated non-paralyzed patient is not going to do well with an ETT, regardless of their underlying pathology.  Sure, their pressure may come down simply by being sedated some, but that still doesn't make it an antihypertensive.


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## TransportJockey (Oct 20, 2013)

jwk said:


> No antihypertensives available?  That seems strange.  I would have thought that would be pretty standard.  We carried them 30 years ago.



Nope. It's one of the few areas NM is behind on. When I worked in Texas we carried metoprolol. Here in NM, NTG is the only med I carry that could be used as such but all we carry are tabs. We are supposed to be getting paste as well and the rumor with the new state scope of practice is that we will possibly be getting beta blockers for something other than transport only meds.


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## Rialaigh (Oct 22, 2013)

From the minimal research I have done on hypertension prehospitally and in the ER setting, I just don't see a justification for having the benefit outweigh the potential risks of attempting to treat in the field at all.

Many progressive ER doctors will send patients home with a BP of 230/150, because they are in hypertensive urgency, which is entirely different from hypertensive emergency (or crisis). I would be very careful dropping the BP on anyone who has any neuro symptoms at all, I would be careful dropping the BP on dialysis patients or anyone with impaired kidney function. I just don't see that us taking a shot at correcting hypertension in the field on transports of less than an hour is worth anything at all. 

maybe one of our forum physicians could enlighten me with some research or studies showing benefit to rapid reduction of BP in any conditions that are "diagnosable" in the field.


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## Carlos Danger (Oct 22, 2013)

Rialaigh said:


> From the minimal research I have done on hypertension prehospitally and in the ER setting, *I just don't see a justification for having the benefit outweigh the potential risks of attempting to treat in the field at all.*
> 
> Many progressive ER doctors will send patients home with a BP of 230/150, because they are in hypertensive urgency, which is entirely different from hypertensive emergency (or crisis). *I would be very careful dropping the BP on anyone who has any neuro symptoms at all, I would be careful dropping the BP on dialysis patients or anyone with impaired kidney function*. I just don't see that us taking a shot at correcting hypertension in the field on transports of less than an hour is worth anything at all.
> 
> maybe one of our forum physicians could enlighten me with some research or studies showing benefit to rapid reduction of BP in any conditions that are "diagnosable" in the field.



I think you are correct in general about not attempting to treat hypertension - even severe hypertension - prehospitally. There is just too much to it, and very often the patient has been that way for days or weeks or longer, and it simply isn't emergent. 

However, if a leaking aortic dissection is present along with severe hypertension, you have a hypertensive _emergency_ of the highest order. In that case I think it is very appropriate to attempt to bring the BP and HR down some, providing you have the means to do so. 

But to be honest, I don't know what the literature says. Perhaps there have been studies done on prehospital management of BP during aortic dissection that show it actually isn't beneficial. Maybe someone here has the time to look into it.


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## Rialaigh (Oct 22, 2013)

Halothane said:


> I think you are correct in general about not attempting to treat hypertension - even severe hypertension - prehospitally. There is just too much to it, and very often the patient has been that way for days or weeks or longer, and it simply isn't emergent.
> 
> *However, if a leaking aortic dissection is present along with severe hypertension, you have a hypertensive emergency of the highest order. In that case I think it is very appropriate to attempt to bring the BP and HR down some, providing you have the means to do so. *
> 
> But to be honest, I don't know what the literature says. Perhaps there have been studies done on prehospital management of BP during aortic dissection that show it actually isn't beneficial. Maybe someone here has the time to look into it.




I'm all about this if it is evidence based. However based on all the EMS "education" issues I would think it would result in many many many people getting unneeded medication possibly resulting in poor brain perfusion or even hypotensive crisis with inadequate MAP. I just don't think we have the education and experience to try and medicate this very small patient population properly unless someone can come up with a set of rules or a scoring index that would indicate medicating based upon a physical exam and history, 

Id love to see if there is a study out there, I may do some looking later tonight.


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