# Hypertensive Emergencies



## MagicTyler (Jul 15, 2013)

When do you consider treating hypertension? 
I had a call for a 67 yo make who called 911 for confusion. Pt was not sure why he was checked into a hotel, and didn't know what city he was in. Denies any pain, dizzy, or SOB, and stroke FAST is negative. After contacting his wife, we learned he was on his way to visit his daughter. Pt has hx of DM 2 and takes regular insulin. Per wife no history of HTN and BP normally runs low. Vitals are: 198/108, hr-76 NSR, resp-18, spo2-98%RA, BGL 267. 

I was working with another medic and it was her call. I started a line (saline lock) while fire called wife. I suggested to medic maybe some NTG SL for the BP. She gave me a funny look and said that's thinking outside the box. We were only ten minutes from the hospital, so we transported without any medication intervention. If it had been my call, I probably would have treated the BP, what do you guys think?


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## Carlos Danger (Jul 15, 2013)

I wouldn't if you were only 10 minutes from the ED. There are much better meds than SL NTG for this scenario. 

What is "stroke FAST"?


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## abckidsmom (Jul 15, 2013)

FAST exam is Cincinnati stroke Eval right?

The trouble with "treating" blood pressure with nitrates is that you have no idea why the pressure is high, and a potentially harmful setup if you lower it through the back door with nitro. 

This guy's pressure isn't even all that high, if you account for the anxiety of the ambulance, the confusion, I bet in 30 minutes it will be back down out of the sky and something much more reasonable. 

What are some causes of hypertension that you know of? 

What is the caution with giving nitrates in general?


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## NomadicMedic (Jul 15, 2013)

I would not have treated his pressure with NTG. In the event he was having a HTN crisis, I might have used Labetalol, but as others have said, he didn't seem to be having a hypertensive incident. Following a sugar and a 12 lead, he would have gotten a calm ride to the ED.


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## VFlutter (Jul 15, 2013)

Personally I would not treat until the patient was 220/120+ or significantly symptomatic. Especially if all you have is SL Nitro which is a horrible choice for hypertensive crisis. As mentioned Labetalol is a good choice if you have it but if not wait until the ER.


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## TransportJockey (Jul 15, 2013)

Nope wouldn't treat HTN w/ SL nitrates. Especially not with his presentation. Honestly if you only have ten minutes transport no meds needed. If you carried a beta blocker, then maybe.


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## Rialaigh (Jul 15, 2013)

I wouldn't treat it in the field barring really extreme circumstances. I have seen many a patient come into the ER with a "HTN crisis" and spend hours with their pressure 220/120 or higher. The idea is to lower the pressure slowly, consistently, and under careful supervision. Unless your transport time is an hour or an hour and a half plus I wouldn't consider treating in the field, even with long transport times I would consult medical control to ask what they wanted me to do. 

Stroke like symptoms or deteriorating patient would warrant treatment with long transports but again, I would likely consult medical control.


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## polisciaggie (Jul 15, 2013)

I wouldn't treat this either. 

I've never treated HTN in the field actually, but my current protocol allows for metoprolol to be used. I've always been hesitant to reduce BP after I saw a patient stroke in the ED because the Physician dropped the pressure too much/fast. 

We're in the process of updating our protocols and will have Labetalol or Hydralazine to use.


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## Aprz (Jul 15, 2013)

Transient Ischemic Attack (TIA), intracranial hemorrhage, or some sort of lesion in the brain would still be high on my differential even if he was negative for FAST. Have you ever heard of the Miami Emergency Neurological Deficient (MEND) exam? Sometimes they are negative when using FAST or LA Prehospital Stroke Screen (LAPSS), but still have neurological deficits that aren't picked up by those exams.

Do you guys think that his blood glucose level (BGL) would have anything to do with his hypertension? I kinda doubt that his BGL would be the primary reason that they had hypertension even though it's kinda high. It's just not really that high. Glucose draws fluid from tissues and cells and into the intravascular space where the glucose is at; it's hyperosmolar. That's why it's necrotic when extravasation occurs.

I regularly see 20 mg Labetolol IV or a Nicardipine (Cardene) drip (suppose to start off 5 mg/hour) used for treating hypertension when attempting to titrate the mean arterial pressure (MAP) to about 110 mm Hg in head bleeds. Not sure if that's correct or not, but that's what see right now in my area. I've seen Cardene drips a lot lately actually.

I was considering doing my internship at Regional Emergency Medical Services Authority (REMSA) in Reno, Nevada. In their protocol, they can treat hypertension (SBP >140 mm Hg) and tachycardia (HR > 100) if STEMI with 5 mg Metoprolol IV.

http://www.remsa-cf.com/remsa-protocols-aug-2012.pdf

I've seen esmolol and nitroprusside used to lower blood pressure with dissecting aneurysms, not necessarily for hypertension.

Although I've seen these medications used for hypertension, I don't really feel comfortable treating hypertension especially if I believe it's a compensatory mechanism (Cushing's triad, Cushing's reflex). Hypotension is one of the killers for head bleeds (along with hypercapnea, hypoxia, and hyperoxia I think). Even though nitroglycerin has a really short half life, I think it could do some damage if the hypertension is a compensatory mechanism.

Isn't what Chase said (SBP >220 or DBP >120) one of the criteria to not give clot busting drugs like tPA? So I guess you'd treat it then so you could make them a candidate for tPA (or another clot buster)?

*Edit* One other random thing I can think I can add to the differential is maybe hepatic encephalopathy?


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## usalsfyre (Jul 15, 2013)

Almost never. If you used NTG solely as an antihypertensive on that call in my system you'd be getting a phone call and would quite likely end up in the clinical office for a meeting. It's not a great idea.

There's very, very few reasons outside of chest pain or CHF to treat hypertension in the field.


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## tacitblue (Jul 15, 2013)

I wouldn't treat his hypertension. As others have pointed out, it seems unlikely he is having a crisis. His delirium- what is causing it is another question. If he had a normal neuro exam, glucose, and electrolytes it may be something benign and temporary like transient global amnesia or a fugue episode.


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## tchristifulli (Jul 15, 2013)

Rialaigh said:


> I wouldn't treat it in the field barring really extreme circumstances. I have seen many a patient come into the ER with a "HTN crisis" and spend hours with their pressure 220/120 or higher. The idea is to lower the pressure slowly, consistently, and under careful supervision. Unless your transport time is an hour or an hour and a half plus I wouldn't consider treating in the field, even with long transport times I would consult medical control to ask what they wanted me to do.
> 
> Stroke like symptoms or deteriorating patient would warrant treatment with long transports but again, I would likely consult medical control.



Agreed, not knowing the origin of the bleed and cause limits us alot prehospital. Nitro could drop this pressure to fast and cause watershed stroke. There's a reason his Bp has elevated. If there is a bleed, he might still be perfusing the brain at this pressure. Watch for reflexive bradycardia as a sign of increased icp. We only use labatelol on interfacility transports. Where we have a CT, Labs and a target map.


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## Carlos Danger (Jul 15, 2013)

Aprz said:


> Do you guys think that his blood glucose level (BGL) would have anything to do with his hypertension?



Not if his kidneys are working (which they may not be, if he has long standing / poorly controlled DM); they would excrete the extra water quickly.


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## Handsome Robb (Jul 15, 2013)

Aprz said:


> I was considering doing my internship at Regional Emergency Medical Services Authority (REMSA) in Reno, Nevada. In their protocol, they can treat hypertension (SBP >140 mm Hg) and tachycardia (HR > 100) if STEMI with 5 mg Metoprolol IV.
> 
> http://www.remsa-cf.com/remsa-protocols-aug-2012.pdf



It'll be pages 41-*43* to be specific since the link its to the entire list of protocols. 

That's a protocol specific to tachycardic, hypertensive STEMI patients although its not unheard of for people to call for it in other cases as well. 

This patient doesn't scream HTN crisis at me, personally. I've called and gotten orders for metoprolol in short transport situations but that patient was very symptomatic. Like everyone said, there's more to it than fixing numbers.


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## Akulahawk (Jul 15, 2013)

MagicTyler said:


> When do you consider treating hypertension?
> I had a call for a 67 yo make who called 911 for confusion. Pt was not sure why he was checked into a hotel, and didn't know what city he was in. Denies any pain, dizzy, or SOB, and stroke FAST is negative. After contacting his wife, we learned he was on his way to visit his daughter. Pt has hx of DM 2 and takes regular insulin. Per wife no history of HTN and BP normally runs low. Vitals are: 198/108, hr-76 NSR, resp-18, spo2-98%RA, BGL 267.
> 
> I was working with another medic and it was her call. I started a line (saline lock) while fire called wife. I suggested to medic maybe some NTG SL for the BP. She gave me a funny look and said that's thinking outside the box. We were only ten minutes from the hospital, so we transported without any medication intervention. If it had been my call, I probably would have treated the BP, what do you guys think?


What was this guy's skin signs? What did he look like?


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## VFlutter (Jul 15, 2013)

Aprz said:


> Isn't what Chase said (SBP >220 or DBP >120) one of the criteria to not give clot busting drugs like tPA? So I guess you'd treat it then so you could make them a candidate for tPA (or another clot buster)?



Correct, they will not give tPA to a hypertensive patient however that is not justification to treat hypertension in the field. In an acute stroke that hypertension may be the only thing maintaing adequate cerebral perfusion. You want to keep them hypertensive (Adequte MAP) up until the point that tPA is about to be given.

Hypotension, or relative hypotension, increases mortality in stroke patients. Slamming IV Beta blockers does more harm then good in most cases. 

It is a weird feeling the first time you hang pressors to maintain crazy high MAPs in Neuro patients.


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## Merck (Jul 15, 2013)

Aprz said:


> In their protocol, they can treat hypertension (SBP >140 mm Hg) and tachycardia (HR > 100) if STEMI with 5 mg Metoprolol IV.



Really?


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## Wheel (Jul 15, 2013)

Chase said:


> Correct, they will not give tPA to a hypertensive patient however that is not justification to treat hypertension in the field. In an acute stroke that hypertension may be the only thing maintaing adequate cerebral perfusion. You want to keep them hypertensive (Adequte MAP) up until the point that tPA is about to be given.
> 
> Hypotension, or relative hypotension, increases mortality in stroke patients. Slamming IV Beta blockers does more harm then good in most cases.
> 
> It is a weird feeling the first time you hang pressors to maintain crazy high MAPs in Neuro patients.



I agree that there's no use treating this in the field with guesses about the etiology of the (possible) stroke when this is likely not going to be a permanently detrimental pressure. The hospital has the luxury of imaging to confirm and aid in guiding treatment. I'd leave this patient's pressure alone for the time being.


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## Carlos Danger (Jul 15, 2013)

Merck said:


> Aprz said:
> 
> 
> > In their protocol, they can treat hypertension (SBP >140 mm Hg) and tachycardia (HR > 100) if STEMI with 5 mg Metoprolol IV.
> ...



Yeah, that's a pretty common protocol for STEMI.


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## Handsome Robb (Jul 15, 2013)

Merck said:


> Really?



Yes.


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## Aprz (Jul 15, 2013)

Merck said:


> Really?


The link below that paragraph is my source. Like Robb said, it's highlighted on page 43.


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## Merck (Jul 16, 2013)

Ok, in the context of the thread it implied that was the protocol for hypertension, which seemed odd.  Still, I don't think IV BBs are really indicated in STEMI there either but to each their own.


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## Aprz (Jul 16, 2013)

> β-Blockers
> 
> *Indications (Apply to all β-blockers)*
> 
> ...


Hazinski, M., Samson, R. and Schexnayder, S. 2010. 2010 handbook of emergency cardiovascular care for healthcare providers. Dallas, TX: American Heart Association.

Wouldn't the same rationale apply to administering a class II/beta blocker as administering nitroglycerin to patients experiencing a myocardial infarction?

By the way, it mentions both labetolol for intracranial hemorrhage or ischemia, and beta blockers for STEMI with tachycardia and hypertension.

I think most of us were thinking that this isn't isolated hypertension. I personally was thinking about intracranial hemorrhage, ischemia, edema, etc.


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## Carlos Danger (Jul 16, 2013)

Merck said:


> Still, I don't think IV BBs are really indicated in STEMI there either but to each their own.



In the setting of STEMI and lacking any contraindications, oral BB's are an AHA class I recommendation and IV BB's are class IIa recommendation. 

I know that there have been studies that have called into question the necessity or efficacy of this practice, though. 

What I was taught by my medical directors early in my career (and what I think the protocol's intent is) was that BB's should be used as an adjunctive therapy to reduce MV02 if the patient remained tachycardic after NTG and opioid administration. 

In actual practice, I don't see BB's used for STEMI that much in the EMS or ED setting; I suspect it's because EMS just doesn't usually get around to it, and the the ED the patient is usually sent to the CL quickly. 

When I have seen BB's used, it often seems to be in very small doses as part of a rigid protocol where they give ASA-PLAVIX-NTG-MS-BB in rapid-fire fashion without really giving the opioids time to work (peak affect of MS is like 25 min) or really assessing for the need for BB's.  




> *Class I*
> 
> Definitely recommended. Definitive, excellent evidence provides support.
> Definition:
> ...


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## Merck (Jul 16, 2013)

Thank Halothane, that was my point.  We don't use IV beta blockers unless there is some outside indication for it.  Of course oral beta blockers are indicated within 24 hours, and usually given sooner.

As to the original metoprolol is not the best choice for a hypertensive emergency.


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## Mickster (Jul 17, 2013)

Why hasn't anybody discussed the BGL. Couldn't that level presented be the cause of the HTN?


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## Aprz (Jul 17, 2013)

Mickster said:


> Why hasn't anybody discussed the BGL. Couldn't that level presented be the cause of the HTN?


I brought it up earlier.



Aprz said:


> Do you guys think that his blood glucose level (BGL) would have anything to do with his hypertension? I kinda doubt that his BGL would be the primary reason that they had hypertension even though it's kinda high. It's just not really that high. Glucose draws fluid from tissues and cells and into the intravascular space where the glucose is at; it's hyperosmolar. That's why it's necrotic when extravasation occurs.


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## usalsfyre (Jul 17, 2013)

A BGL of 267 shouldn't make you hyperosmolar enough to have a significant effect on B/P. In otherwise healthy patients the kidneys do a good enough job of controlling water balance to avoid hypertension.


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## NCmedic42 (Jul 18, 2013)

I would stay a way from treating hypertension in the field.  For one you do not know why the patient is hypertensive to begin with,  they could be having a bleed and the pressure is stopping it from bleeding to much.  I know that in the most recent NC protocols t doesn't give a treatment for hypertension for the reason of not knowing what the cause is.


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## Handsome Robb (Jul 18, 2013)

NCmedic42 said:


> I would stay a way from treating hypertension in the field.  For one you do not know why the patient is hypertensive to begin with,  *they could be having a bleed and the pressure is stopping it from bleeding to much.*  I know that in the most recent NC protocols t doesn't give a treatment for hypertension for the reason of not knowing what the cause is.



Wait what? 

That's not why patients with intracranial bleeds are hypertensive. Hypertension in the presence of increased intracranial pressure is a compensatory mechanism in attempt to provide adequate cerebral perfusion pressure. Not to "stop it from bleeding too much". The body increases blood pressure, particularly systolic blood pressure, to attempt to overcome the increased pressure in the brain in order to deliver oxygenated blood as well as transport waste products out (ie CO2). It's a vicious cycle though the HTN increases ICP as well...

In response to this increase in blood pressure the baroreceptors slow the heart trying to reduce the blood pressure. 

Irregular respirations come from direct pressure on the brainstem causing respiratory dysfunction. 

Hence Cushing's Triad.

I agree you need to be cautious treating hypertension in the field but that's been discussed pretty well earlier in this thread.


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## tacitblue (Jul 18, 2013)

Hypertension in the setting of stroke or bleed is a common finding but very nonspecific. It could be chronic hypertension (and may have been a contributing or at least concomitant factor in the stroke), acute hypertension from numerous causes including anxiety about stroke symptoms, or as Rob said the result of Cushing's reflex. 

A neuro-interventionalist who our CCT service brings patients who failed tPA would start them on nicardipine if they where hypertensive. I don't know if this was therapeutic for the stroke itself or if lowering BP was necessary before he brought the patient to the cath lab.


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## NCmedic42 (Jul 18, 2013)

I was not trying to say that the bleed is the reason they are hypertensive.  I was merely trying to point out that  with someone who is having a brain bleed and is hypertensive is that the hypertension could be helping out.  If you have a bleed or leak and apply pressure to the source it will slow down with enough pressure.  So if you give something like nitro and reduce the pressure the bleed could get a lot worse.


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## Carlos Danger (Jul 18, 2013)

NCmedic42 said:


> I was not trying to say that the bleed is the reason they are hypertensive.  I was merely trying to point out that  with someone who is having a brain bleed and is hypertensive is that the hypertension could be helping out.  If you have a bleed or leak and apply pressure to the source it will slow down with enough pressure.  So if you give something like nitro and reduce the pressure the bleed could get a lot worse.



Picture you have a hose with a small hole in it. The higher you turn up the water pressure, the faster the water leaks out of the hole. The lower you turn down the water pressure, the slower it leaks out the hole. Now, think of the blood vessels in your brain as small hoses. If one of those vessels is leaking, lowering the BP will slow the leak. 

However, lowering the BP will also reduce the amount of blood that will be delivered to the brain tissue, which can cause problems even faster than the bleed itself will, because when pressure in the cranium is increased, your brain NEEDS the higher blood pressure in order to get the blood that it needs. That is why we don't try to lower the BP of hypertensive patients who may have a bleed.

You are right that at a certain point, the ICP will have increased enough that it will tamponade the bleeding, and that in a bad bleed, lowering the BP may actually make the bleed even worse. However, your body can increase MAP (and in turn ICP) far, far higher than what it takes to cause fatal brainstem compression, so if the bleed is bad, we can't rely on increasing ICP to tamponade the bleed. In other words, your brain tissue can only be exposed to so much pressure before it becomes fatal, and if it is a bad bleed, the "tamponade pressure" will probably be well above the "fatal pressure".

Bleed + hypertension = very bad. These patients need to have scans done and be seen by a neurosurgeon yesterday. All that can be done in the field is supportive care. 

The Brain Trauma Foundation has some good stuff on this, including educational materials and EMS protocols that are evidence-based. Traumatic and non-traumatic bleeds are different, but the general principles surrounding them are the same.


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## VFlutter (Jul 18, 2013)

NCmedic42 said:


> I was not trying to say that the bleed is the reason they are hypertensive.  I was merely trying to point out that  with someone who is having a brain bleed and is hypertensive is that the hypertension could be helping out.  If you have a bleed or leak and apply pressure to the source it will slow down with enough pressure.  So if you give something like nitro and reduce the pressure the bleed could get a lot worse.



Eh, your general concept is correct but not quite now it works from a pathophysiology stand point.

Edit: Halothane nailed it for me


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