# Lasix pre-med control



## sneauxpod (Dec 4, 2012)

So Im not sure how everyone else's protocol reads, but for HEMS in SE Michigan it says that Lasix is post radio. Before I go further, I am an idiot and didnt realize that it had changed from the last issue of our books from pre to post. With that being said, I was torn a new one by the med director for giving 40 of lasix pre radio (which is the proper dose here). The guy was unresponsive at home, glucose was about 170, no opiates, barbs or meds of any kind and had a BP of 250/140. No history or signs of CVA/TIA, cardiac history, he had mild hypertension (not medicated) with a usual of 140/90-ish. Literally the only thing that was wrong with this person was his sky high BP. Do you think that this was an appropriate move on my part? I mean protocol is there for a reason, but from what ive always been told, theyre more guidelines than concrete rules. adding to this, after I finished my report, i walked by to see how they were doing, and he was AOx3 with a BP of around 130/80.


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## Anjel (Dec 4, 2012)

We have lasix for pulmonary edema. Not HTN. 

So yes I think that was inappropriate. Also it is post radio for a reason.


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## Clare (Dec 4, 2012)

Sorry mate I don't understand.  Did you not tell the hospital you'd given him frusemide? If that is the case I can understand why they were a little annoyed but it should have still been documented on your patient report form anyway which in theory the hospital should have read!  

Frusemide was recently withdrawn in the 2011 Clinical Practice Guidelines for cardiogenic pulmonary edema and had been progressively de-emphasised for a number of years as far back as 2009.  

While frusemide is a good option for long term management of stable chronic cardiac failure it is not a good idea for acute presentations.  There is a common misunderstanding that acute cardiogenic pulmonary oedema is from hypervolaemia and this is not the case; the acute problem is fluid shift from the pulmonary circulation to the alveoli because as the left ventricle fails to eject properly the pulmonary hydrostatic pressure increases above what can be tolerated.  

These patients are in fact relatively hypovolaemic and frusemide is just going to make the problem worse and potentially deplete electrolytes like potassium and sodium.  

Did this patient have signs of acute cardiogenic pulmonary edema? You do not describe whether he had cyanosis, shortness of breath, hypoxia/SpO2, significant crackles, 12 lead ECG evidence of dysrhythmia or infarction (the two most common causes of acute APO) etc?

In the absence of any of those I have to say no, that I would not give this patient frusemide, but then again I would not give any acute CHF patient frusemide.  

If you suspected CHF/APO and there was objective clinical signs of it, you are far better off giving him some GTN.


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## NYMedic828 (Dec 4, 2012)

He isn't mad at you for administering lasix without calling so much as he is for administering a medication that is not indicated for the condition. More often than not if you administer a medication that isn't standing order without asking mom/dad you will get a talking to but it will end in a don't do it again but good job, if the treatment was just.

Some services carry beta blockers for treating acute hypertension but Lasix is not meant for the same purposes.

Lasix is meant to be administered to a patient who is hypervolemic which is actually rarer than you might think. (acutely)

More on pulmonary edema below from Dr. Amal Mattu if you are interested. Great read.

https://secure.muhealth.org/~ed/students/articles/emmedclinna_23_p1105.pdf

Anyway,

If he was unconscious, with that BP id be looking for a neurological condition or a hypoxic condition such as pulmonary edema.  A TIA is a very real possibility amongst other things.

You did the right thing in checking BGL, so hypo/hyperglycemia is out.

I would sooner administer nitroglycerin as a means of lowering BP than I would furosemide. I would also monitor the airway and consider intubation if things kept declining. Otherwise just start an IV and go to the hospital. Sometimes there is no thing we can do but more harm.

Protocols are meant to be guidelines but at the same time they exist for when you don't fully understand a treatment. Most people don't understand lasix and when its indicated (which is very rarely) and as such it is a medical control option. 

Though they are guidelines, you MAY NOT exceed their allowances without following procedure as they are written.


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## sneauxpod (Dec 4, 2012)

Ill add a little more, family said the pt had been normal all day, last time pt had been seen normal was around 11pm when he went to bed. The call occurred around 3am. No trauma, pupils equal and reactive, very strong almost pounding pulse at a rate around 70-80. This guy was in great shape from his looks and all the exercise stuff we saw on scene and the only medical problem that they said he had was the hypertension which was mild and not medicated.



Clare said:


> Sorry mate I don't understand.  Did you not tell the hospital you'd given him frusemide?



No I told them in the report as we were transporting after i had given it and also to the Dr who was assessing when we got there. He didnt seem to have a problem with it but one of the nurses did and kept coming back to make sure that I did it. She came back and asked probably 6 times.



Clare said:


> Did this patient have signs of acute cardiogenic pulmonary edema? You do not describe whether he had cyanosis, shortness of breath, hypoxia/SpO2, significant crackles, 12 lead ECG evidence of dysrhythmia or infarction (the two most common causes of acute APO) etc?



He was normal sinus on the monitor, shallow breathing but a pulseox of 99% on ours and the FD who responded first, from what I could hear lungs sounded clear but we are also going code down bad roads. as we were pulling into the hospital though his responsiveness changed to painful (sternal rub) and like i said above, about 20mins after we transferred care, he was AOx3 and had a good BP. 



NYMedic828 said:


> He isn't mad at you for administering lasix without calling so much as he is for administering a medication that is not indicated for the condition. More often than not if you administer a medication that isn't standing order without asking mom/dad you will get a talking to but it will end in a don't do it again but good job, if the treatment was just.



Actually he seemed more irate that I didnt ask first, it seemed like he had accepted my explanation as to why the decision was made, but it was more of a talking to and a "dont do it again" talk. 



NYMedic828 said:


> If he was unconscious, with that BP id be looking for a neurological condition or a hypoxic condition such as pulmonary edema.  A TIA is a very real possibility amongst other things.



There were no signs of hypoxia though, and even so we put him on high flow O2. Also, he didnt exhibit typical signs of CVA/TIA that was could assess, I thought it could be respiratory/ metabolic alkalosis at first, but becoming unresponsive from that would have a lot of symptoms prior which the family said that he didnt have.  



NYMedic828 said:


> You did the right thing in checking BGL, so hypo/hyperglycemia is out.



Yeah, that was actually my first thought on scene was hypoglycemia. After the check and history though, everyone was pretty much baffled as to what it could be because of everything stated above. My partner whos been a medic basically forever after the call just told me that he agreed with my course of action and that this was just a weird call in general. The only other thing that we could think of was a carbon monoxide poisoning but no one else in the house had any symptoms of it nor did he before he went to bed. thanks for the feedback so far though


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## Veneficus (Dec 4, 2012)

Lasix can be used as an emergent treatment to bring down blood pressure.

Having said that, it is not a first line treatment to use it for such. There are much better options. 

Many EMS systems do not have such options and a balance must be struck between watchful waiting on the way to the ED or going with a second or third line out of protocol option.

Lasix is used to treat hypertension in conjunction with another medication, not as a stand alone treatment in all of the recent guidlines I have seen. It is also usally the third drug added to a coctail. 

Bottom line, you were administering a med out of protocol. For all intents and purposes you were practicing medicine independantly.

That is a felony most places.

Did it help? It probably had a positive impact.

You would have been much better off calling in though.


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## NYMedic828 (Dec 4, 2012)

Unconsciousness is a pretty assessable sign of potential CVA...

What would lead you to believe alkalosis? That's a very uncommon finding as opposed to acidosis.

Lungs should have been assessed prior to moving... There's no need to rush 99% of the time and it would be safer for everyone and benefit the patient more to take it nice and easy then arriving 30 seconds sooner to the ER.

The Lasix didn't hurt the patient thankfully but it wasn't neccesarily indicated either. More importantly it was out of protocol...


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## STXmedic (Dec 4, 2012)

Acute onset of unresponsiveness with severe hypertension and CVA/TIA wasn't near or at the top of your list for differentials? You aren't going to see unilateral weakness when the patient is unconscious/unresponsive. Pupils could also be normal.

I'll echo what others have said. I wouldn't consider furosemide unless I was provided significant evidence of fluid overload. Nitro or labetolol would be in his future. If he was "borderline hypertensive" and unmedicated, when is the last time he saw his PCP? If he was told he was borderline three years ago and hasn't gone back since, a lot could've changed without him knowing it. The fact that he came around without significant intervention (unless the ER did something right after you transferred him) makes me think TIA.


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## JPINFV (Dec 4, 2012)

Also, unless you're someplace where transport time is measured in multiple hours, there's very little reason to reduce BP in a hypertensive emergency prehospital. A drop of over half the initial blood pressure in such a short amount of time is dangerous and can, on it's own, cause ischemia.


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## sneauxpod (Dec 4, 2012)

Veneficus said:


> Lasix can be used as an emergent treatment to bring down blood pressure.
> 
> Having said that, it is not a first line treatment to use it for such. There are much better options.
> 
> ...



It had a very positive impact, within about 5mins he went from totally unresponsive to painful and within 20mins he was AOx3. In hindsight I agree that there were better options, but hindsight is always 20/20. Technically I couldnt act in or out of protocol because in HEMS there is no protocol for hypertension. Im not saying it was right to go to that straight away, but there really isnt anything that says I cant. There is a protocol for CHF/Pulm Edema if you want to consider that the hypertensive protocol though. heres a link to the website that gives them. 

http://www.hems.org/



> Unconsciousness is a pretty assessable sign of potential CVA



but like I said, with that being his only symptom, no prior history and no signs of shock from a major event? If he had a stroke either severe enough or for the extended period of time it would take for him to be totally unresponsive that he would have an accelerated heart rate at least. That was the general consensus between everyone on scene. And it worked, which is the important part.



> The fact that he came around without significant intervention (unless the ER did something right after you transferred him) makes me think TIA.



With his systolic dropping over 100 and diastolic dropping almost in half i dont think a TIA was to blame. that is way too significant of a rise and drop from what ive been taught about TIAs. The ER staff could have done something else while i wasnt looking but I was in view of the pt for a majority of my report writing.


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## VFlutter (Dec 4, 2012)

I was so confused when you kept saying HEMS I thought you were a fight medic. I was starting to get worried :wacko:

"but like I said, with that being his only symptom, no prior history and no signs of shock from a major event? If he had a stroke either severe enough or for the extended period of time it would take for him to be totally unresponsive that he would have an *accelerated heart rate a*t least. That was the general consensus between everyone on scene. And it worked, which is the important part." 

An undiagnosed cerebral aneurysm can be asymptomatic and quickly lead to a massive hemorrhage. Also, I would suggest going over Cushing's triad....


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## FLdoc2011 (Dec 4, 2012)

sneauxpod said:


> With his systolic dropping over 100 and diastolic dropping almost in half i dont think a TIA was to blame. that is way too significant of a rise and drop from what ive been taught about TIAs. The ER staff could have done something else while i wasnt looking but I was in view of the pt for a majority of my report writing.



How much did he drop and how quickly??

If he didn't have a stroke before he may have one now.


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## NYMedic828 (Dec 4, 2012)

sneauxpod said:


> It had a very positive impact, within about 5mins he went from totally unresponsive to painful and within 20mins he was AOx3. In hindsight I agree that there were better options, but hindsight is always 20/20. Technically I couldnt act in or out of protocol because in HEMS there is no protocol for hypertension. Im not saying it was right to go to that straight away, but there really isnt anything that says I cant. There is a protocol for CHF/Pulm Edema if you want to consider that the hypertensive protocol though. heres a link to the website that gives them.



No offense, but I don't think the Lasix was the reason for his improvement. The onset of Lasix is not that rapid and can be sporadic depending upon renal blood flow, which in times of bodily crisis, is diminished. There are studies claiming Lasix has a direct vasodilatory effect but none that I read have any conclusive evidence. He probably had quite the urge to urinate later on though...





> but like I said, with that being his only symptom, no prior history and no signs of shock from a major event? If he had a stroke either severe enough or for the extended period of time it would take for him to be totally unresponsive that he would have an accelerated heart rate at least. That was the general consensus between everyone on scene. And it worked, which is the important part.



Has to be a first time for every condition right? How else would we acquire a history if the first occurrence never occurrd?

Why does he need to have an elevated heartrate? Cerebral bleeding/ischemia can cause varying, sometimes strange/unexpected signs and symptoms.



> With his systolic dropping over 100 and diastolic dropping almost in half i dont think a TIA was to blame. that is way too significant of a rise and drop from what ive been taught about TIAs. The ER staff could have done something else while i wasnt looking but I was in view of the pt for a majority of my report writing.



Says who? A CVA can, why can't a TIA? After all a TIA is just a CVA that resolves on its own in a certain time frame. 


 What you've been taught isn't neccesarily correct. (Not saying it isn't, just devils advocate)

Medicine also changes rapidly. We believe something one day and the next we find out we were completely in left field. The bigger issue is that EMS usually doesn't get wind of it until a couple years later.


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## VFlutter (Dec 4, 2012)

NYMedic828 said:


> No offense, but I don't think the Lasix was the reason for his improvement. The onset of Lasix is not that rapid and can be sporadic depending upon renal blood flow, which in times of bodily crisis, is diminished. There are studies claiming Lasix has a direct vasodilatory effect but none that I read have any conclusive evidence.



IIRC the onset of action for IV lasix is 15-20 mins with a slow IV push. I have always been told there could be an ubrupt drop in pressure with a rapid IV push however I have never personally seen it (even with a MD slamming a large bolus) and we give it multiple times a day on my floor. 


How fast did you push it?


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## NYMedic828 (Dec 4, 2012)

Also, another note, if there is no protocol, that means you can't do it. It doesn't mean you can fabricate your own means of treatment because then you would be practicing medicine. Without a license. Which is a felony.

The only way to act outside your standing orders is verbal approval from your medical director to do so.


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## sneauxpod (Dec 4, 2012)

> An undiagnosed cerebral aneurysm can be asymptomatic and quickly lead to a massive hemorrhage. Also, I would suggest going over Cushing's triad....



True, but if it was a massive hemorrhage wouldnt there be some type of pupil dilation? and also the body would start compensating for shock since the brain isnt getting all the O2 it needs. Thats actually something that didnt come up, but that wouldnt really be considered, he wasnt bradycardic, the systolic and diastolic were high and his resps were regular, just shallow. 



> How much did he drop and how quickly??



He went from about 250/140 to 140/80. they were something along those lines. 




> IIRC the onset of action for IV lasix is 15-20 mins with a slow IV push. I have always been told there could be an ubrupt drop in pressure with a rapid IV push however I have never personally seen it (even with a MD slamming a large bolus) and we give it multiple times a day on my floor.
> How fast did you push it?



I pushed it over about a minute maybe two. there wasnt a significant drop while we were in the truck, it dropped maybe 20/10 in the 15min we were transporting. The last time i looked before we left which was about 45mins after it was pushed, his pressure had dropped down to what i said earlier. 





> Has to be a first time for every condition right? How else would we acquire a history if the first occurrence never occurrd?
> 
> Why does he need to have an elevated heartrate? Cerebral bleeding/ischemia can cause varying, sometimes strange/unexpected signs and symptoms.
> Says who? A CVA can, why can't a TIA? After all a TIA is just a CVA that resolves on its own in a certain time frame.
> ...



I totally agree that sometimes CVA/TIA symptoms can depend on the patient, severity, etc. but at the time, with the symptoms presenting, differential discussion and such i thought it would be the right thing to do, except for the not calling med control part which was just dumb on my part. And it is pretty sad that we dont get wind of a lot of breakthroughs unless we do independent research and even then, we have to wonder how reliable is it exactly.



Id say to sum this all up, there were other routes i should have taken and that i will next time. and always call and ask if theres a question.


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## Anjel (Dec 4, 2012)

I think you would of been better off calling and asking for orders for nitro then lasix. But ya always call, and don't make your own protocols, because there isn't one in place.

You can't do a pericardiocentesis just because there isn't a protocol for cardiac tamponade.


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## JDub (Dec 4, 2012)

Those protocols on your website hurt my brain.


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## sneauxpod (Dec 4, 2012)

Anjel1030 said:


> I think you would of been better off calling and asking for orders for nitro then lasix. But ya always call, and don't make your own protocols, because there isn't one in place.
> 
> You can't do a pericardiocentesis just because there isn't a protocol for cardiac tamponade.



Very true. I feel lucky I only got a slap on the wrists. 



JDub said:


> Those protocols on your website hurt my brain.



yes, they hurt all of ours too.


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## Sublime (Dec 4, 2012)

Clare said:


> Frusemide was recently withdrawn in the 2011 Clinical Practice Guidelines for cardiogenic pulmonary edema and had been progressively de-emphasised for a number of years as far back as 2009.
> 
> While frusemide is a good option for long term management of stable chronic cardiac failure it is not a good idea for acute presentations.  There is a common misunderstanding that acute cardiogenic pulmonary oedema is from hypervolaemia and this is not the case; the acute problem is fluid shift from the pulmonary circulation to the alveoli because as the left ventricle fails to eject properly the pulmonary hydrostatic pressure increases above what can be tolerated.
> 
> ...



Clare said it perfectly. 

Lasix is primarily used for chronic maintenance of CHF patients with peripheral / systemic edema. 

If they have fluid in their lungs fix it with nitro / CPAP. The BP most likely needs to be fixed with a beta-blocker. 

I personally don't think Lasix has much of a place in EMS anymore. A lot of places don't even carry it anymore.



sneauxpod said:


> Literally the only thing that was wrong with this person was his sky high BP.



Uhh, how about the fact he was unconscious? And as others have stated how can you rule out stroke/TIA with that BP in combination with him being unresponsive?



sneauxpod said:


> There were no signs of hypoxia though, and even so we put him on high flow O2.



Why did you put him on high flow 02? I would would of made sure NOT to put him on 02 if he was not experiencing any form of hypoxia. I would suggest reading the effect of hyperoxia and free radical production.

Here's a JEMS article for ya on the subject.

http://www.jems.com/behind-the-mask


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## KellyBracket (Dec 4, 2012)

sneauxpod said:


> ... Do you think that this was an appropriate move on my part? I mean protocol is there for a reason, but from what ive always been told, theyre more guidelines than concrete rules.



I am a strong believer that common sense and medical knowledge should trump rote protocols. But when you deviate from those guidelines, you really need to have a well-reasoned argument why you did so. 

There is a good reason why you _don't_ have hypertension protocols. Frankly, the percentage of patients in the ED who need IV meds for HTN is really, really small. And those who do need therapy, you can't figure out in the field - you need imaging and various tests before you can go there. 

There can be some interesting discussion about what sorts of situations call for "bending" your protocols/guidelines, and what justifies it. I don't believe it automatically makes you a felon, but you better have a real good medical reason. If you do some reading on hypertensive emergencies, and especially the controversies, you'll soon see why this wasn't the best way to get to know the medical director.

I'm curious though - how many people feel uneasy *not* treating a high BP?


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## Aprz (Dec 4, 2012)

sneauxpod said:


> True, but if it was a massive hemorrhage wouldnt there be some type of pupil dilation? and also the body would start compensating for shock since the brain isnt getting all the O2 it needs. Thats actually something that didnt come up, but that wouldnt really be considered, he wasnt bradycardic, the systolic and diastolic were high and his resps were regular, just shallow.


He was saying that you should go over Cushing's Triad because you thought an increase HR would be a sign of a head bleed (Cushing's Triad is for increase intracranial pressure (ICP)), and it's not. It's just a triad of signs and symptoms to help you recognize increase ICP, but you don't need all three, you don't even need one, and just because you have any of them doesn't mean increase ICP is present, it's just a tool to help you remember and be highly suspicious of increase ICP if you see it. If I saw an unresponsive patient who had a high systolic (the triad is widening of the pulse pressure ie high systolic, low diastolic) without irregularly respiration and bradycardia, increase ICP from a stroke or head trauma would still be high on my differential, and furosemide would definitely be inappropriate since the high BP is a mechanism by the body to keep the brain perfusing/vessels open. Cerebral hypoxia/anoxia and stroke aren't forms of shock; shock is a systemic problem.


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## Handsome Robb (Dec 4, 2012)

KellyBracket said:


> I'm curious though - how many people feel uneasy *not* treating a high BP?



I called for orders for metoprolol for a patient with a systolic of 260, visual deficits, a 10/10 headache who was prescribed metoprolol and had run out while on vacation. I was denied, and told to transport. Then they gave it to him while I was still giving the ERP my report  Most of the severely hypertensive patients haven't been all that symptomatic though. 

Only time I've ever even contemplated treating it but I'm also relatively new. 

OP, as to intracranial hemorrhage causing pupil dilation. It doesn't always happen. Depending on where the bleed is. I've seen more than a few patients with bleeds in my short career and only one had a unilaterally dilated pupil.


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## Clare (Dec 4, 2012)

Sublime said:


> Clare said it perfectly.



Why thank you, I do try 



Sublime said:


> I would would of made sure NOT to put him on 02 if he was not experiencing any form of hypoxia. I would suggest reading the effect of hyperoxia and free radical production.



Yes, that is very important and cannot be overemphasised


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## VFlutter (Dec 5, 2012)

Aprz said:


> He was saying that you should go over Cushing's Triad because you thought an increase HR would be a sign of a head bleed (Cushing's Triad is for increase intracranial pressure (ICP)), and it's not. It's just a triad of signs and symptoms to help you recognize increase ICP, but you don't need all three, you don't even need one, and just because you have any of them doesn't mean increase ICP is present, it's just a tool to help you remember and be highly suspicious of increase ICP if you see it. If I saw an unresponsive patient who had a high systolic (the triad is widening of the pulse pressure ie high systolic, low diastolic) without irregularly respiration and bradycardia, increase ICP from a stroke or head trauma would still be high on my differential, and furosemide would definitely be inappropriate since the high BP is a mechanism by the body to keep the brain perfusing/vessels open. Cerebral hypoxia/anoxia and stroke aren't forms of shock; shock is a systemic problem.



I was just trying to point out that his thought process for ruling out CVA/TIA was flawed and physiologically incorrect. 

I should also clarify that Cushing's triad is a late sign and usually indicates impending herniation (within minutes). Also, the Cushing reflex is complex and occurs in 3 stages. During the first stage the patient can in fact be tachycardiac but if the patient is non-responsive they have progressed into the 2nd (Bradycardia) or 3rd stage.

The reflex is a protective measure to maintain CPP so correcting the HTN is probably not a great idea.


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## Clare (Dec 5, 2012)

KellyBracket said:


> I'm curious though - how many people feel uneasy *not* treating a high BP?



No argument here, I have picked up people with BP > 220 systolic and somebody needs their hypertension treated then that is fine, it is not my prerogative to do so.


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## KellyBracket (Dec 5, 2012)

To be sure, they likely need to be started on anti-HTN meds, but it is rarely an emergency, and is usually handled with PO stuff. The high BP will catch up with them, but over the course of months/years, not minutes/hours.

Now, if they have hypertension and _acute_ CHF, then blitz them with NTG!


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## Christopher (Dec 5, 2012)

KellyBracket said:


> I'm curious though - how many people feel uneasy *not* treating a high BP?



Ugh, I hated when we had hypertensive crisis as a protocol and were chastised for not giving labetalol...I don't have the means in my truck to rule-out the nastier causes of a hypertensive crisis in order to safely administer the meds.


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## Aprz (Dec 5, 2012)

ChaseZ33 said:


> I was just trying to point out that his thought process for ruling out CVA/TIA was flawed and physiologically incorrect.


That's what I figured and was trying to say. I was also concern that the OP would think that the patient needs at least one (up to all three) criteria of the triad before considering increase ICP, or that increase ICP is always associated  bradycardia (that they can't be tachycardic), which of course isn't true.


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## Farmer2DO (Dec 7, 2012)

KellyBracket said:


> Now, if they have hypertension and _acute_ CHF, then blitz them with NTG!



And Lasix!

Just kidding.....


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