# Night watch



## Chris EMT J (Jun 15, 2022)

This is a night watch case. It involves a patient suspected stroke. Patient suddenly was unable to talk. When EMS arrived the patient couldn't talk or follow commands. BP was 170/110 and they start transport then in the back on the ambo patient goes unresponsive and BP spikes. Now one thing I noticed that I think was a bad call was they administered nitroglycerin. Strokes could be ether clot or bleed.. ischemic or hemorrhagic... So if this was a bleed stroke nitro would worsen the issue.  Correct me if I am wrong but in a possible stroke should BP control be a priority? I think no but what's your thoughts?


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## MrBrown (Jun 15, 2022)

The most obvious thing I noticed was the treating officer was unrestrained in the back of a moving ambulance.  I admit to doing that myself when the old trolley beds were basically used as a bench seat.  But that was a good few years ago now and since then the new vans have proper seats with seatbelts.  Obviously I've not used them but it is a quantum leap forward.

Stroke is obviously one cause of aphasia, but there can be many.  I am wondering if his sudden onset of very high BP and unresponsiveness is due to a spontaneous cerebral artery rupture.  In these situations, the brain is exposed to mean arterial pressure so all (or most) cerebral blood flow stops because there is no pressure gradient.  This leads to the patient becoming unresponsive and often apnoeic.  

I can only say that yes, I recall that control of HTN in stroke is important.  No, I wouldn't give GTN off the cuff.  I would want to seek advice on that point.  From memory I believe the preference is to give, for example, labetol or such rather than GTN but I'm uncertain.


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## Chris EMT J (Jun 16, 2022)

MrBrown said:


> The most obvious thing I noticed was the treating officer was unrestrained in the back of a moving ambulance.  I admit to doing that myself when the old trolley beds were basically used as a bench seat.  But that was a good few years ago now and since then the new vans have proper seats with seatbelts.  Obviously I've not used them but it is a quantum leap forward.
> 
> Stroke is obviously one cause of aphasia, but there can be many.  I am wondering if his sudden onset of very high BP and unresponsiveness is due to a spontaneous cerebral artery rupture.  In these situations, the brain is exposed to mean arterial pressure so all (or most) cerebral blood flow stops because there is no pressure gradient.  This leads to the patient becoming unresponsive and often apnoeic.
> 
> I can only say that yes, I recall that control of HTN in stroke is important.  No, I wouldn't give GTN off the cuff.  I would want to seek advice on that point.  From memory I believe the preference is to give, for example, labetol or such rather than GTN but I'm uncertain.


So maybe contact med control to ask how to manage a BP with a possible stroke.


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## MrBrown (Jun 16, 2022)

Well, anything is relative isn't it and needs to be considered in light of the entire instant fact pattern.  If the patient is quite distant from hospital and very newly onset hypertensive (so otherwise eutensive) I would seek advice about whether to administer GTN or not.  I wouldn't randomly administer GTN.  If this scenario is 10 or 15 minutes around the corner from hospital, I would be less inclined to worry about it.  One single sign in isolation is n toot really likely be clinically significant (unless, you know, it's tachycardia from VT or something), but taken in context of the facts assessed as a whole, it may well need something done about it.  I guess it would also be a good time to have thoroughly gone through a list of differentials but unless you are confident and capable, for example of a complete cranial nerve exam, then it may not be something you can reasonably look to exclude other causes on history and exam alone, apart from the obvious hypoglycaemia or post-ictal state that can mimic a stroke.


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## DrParasite (Jun 16, 2022)

They are in Yonkers NY... not exactly middle of nowhere.

Would I have administered Nitro?  doubtful.  aphasia + spiking BP is leading me down the stroke path.  strokes can't be fixed prehospitally.  the patient goes unconc, then I'm looking at airway management, and having an interventional neurologist meet us at the ER doors.  As for clinically why  not, if you drop the BP, you will underperfuse the damaged area in the brain and extend the stroke


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## Chris EMT J (Jun 16, 2022)

DrParasite said:


> They are in Yonkers NY... not exactly middle of nowhere.
> 
> Would I have administered Nitro?  doubtful.  aphasia + spiking BP is leading me down the stroke path.  strokes can't be fixed prehospitally.  the patient goes unconc, then I'm looking at airway management, and having an interventional neurologist meet us at the ER doors.  As for clinically why  not, if you drop the BP, you will underperfuse the damaged area in the brain and extend the stroke


That's what I was originally thinking


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## Aprz (Jun 17, 2022)

In IFT CCT, it's pretty routine for us to treat hypertension in acute stroke patients regardless of if it's ischemic or hemorrhagic, however are treatment threshold is different depending on type of stroke or bleed. We usually treat it with Labetalol or Nicardipine, not Nitroglycerin.


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## BobBarker (Jun 18, 2022)

Aprz said:


> In IFT CCT, it's pretty routine for us to treat hypertension in acute stroke patients regardless of if it's ischemic or hemorrhagic, however are treatment threshold is different depending on type of stroke or bleed. We usually treat it with Labetalol or Nicardipine, not Nitroglycerin.


Well prehospital and IFT are different. CCT has orders from the Dr and by that point they have already been examined, scanned, treatment started and going to definitive/higher level of care.


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## E tank (Jun 19, 2022)

Aprz said:


> In IFT CCT, it's pretty routine for us to treat hypertension in acute stroke patients regardless of if it's ischemic or hemorrhagic, however are treatment threshold is different depending on type of stroke or bleed. We usually treat it with Labetalol or Nicardipine, not Nitroglycerin.


Nitroglycerin would be an odd choice at least because for a sustained effect you' need to give it as an infusion because of it's very short half-life. Didn't watch the video but I'm just assuming they did not.


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## DrParasite (Jun 19, 2022)

While not directly related, this might be a helpful read for asymptomatic hypertension https://www.ems1.com/patient-assess...-does-an-elevated-bp-matter-DCvFoc8freQiVlcy/


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