# Hypertension in a BLS scenario



## teufulhund (May 2, 2019)

Pretty simple question, just wondering what your opinions are. 
What’s the max Blood Pressure a BLS unit should except before calling for ALS. 
I know the CC will have a big factor on the outcome, but with the random variables aside, is there a max BP a BLS crew should say okay this guy needs to go ALS?


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## DesertMedic66 (May 2, 2019)

I don’t think there will be just a single value as there are a lot of factors that have to be considered. Just realize that the vast majority of ALS units will not treat hypertension in the field. If you are close to the hospital it is probably better if you go straight in.


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## teufulhund (May 2, 2019)

DesertMedic66 said:


> I don’t think there will be just a single value as there are a lot of factors that have to be considered. Just realize that the vast majority of ALS units will not treat hypertension in the field. If you are close to the hospital it is probably better if you go straight in.


That’s what I was thinking. Unfortunately a lot of my coworkers will deny calls due to a high blood pressure, even if the call is just a discharge to a SNF.


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## DesertMedic66 (May 2, 2019)

teufulhund said:


> That’s what I was thinking. Unfortunately a lot of my coworkers will deny calls due to a high blood pressure, even if the call is just a discharge to a SNF.


Discharges can be a little different. Some SNFs and other non emergency locations have set policies on BP parameters to accept patients. So in this case it would be wise to check with the doctor/nurse to make sure they know the patient is hypertensive before discharge but to also contact the SNF or other facility to see what their guidelines are. We have had BLS and ALS units transfer patients from the ER to other facilities to have those facilities refuse to accept care which makes us have to turn around and go back to the ER.


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## E tank (May 2, 2019)

teufulhund said:


> Pretty simple question, just wondering what your opinions are.
> What’s the max Blood Pressure a BLS unit should except before calling for ALS.
> I know the CC will have a big factor on the outcome, but with the random variables aside, is there a max BP a BLS crew should say okay this guy needs to go ALS?



But the random variables go into the decision....symptomatic? distance to the hospital? presentation (ie  chronic htn, ran out of meds v. possible poisoning or something? Yeah, ALS units don't treat asymptomatic HTN ordinarily, but that doesn't mean the patient won't get symptomatic before a disposition is decided on.


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## Carlos Danger (May 2, 2019)

Some ED guidelines recommend no treatment for even very high BP’s as long as no evidence of end-organ dysfunction exists, and prompt primary care follow up can be expected.

With that in mind, and considering that hypertension should almost never be treated prehospital anyway, I can’t think of any reason for a BLS crew to decline a transport based on a BP alone.


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## teufulhund (May 2, 2019)

Remi said:


> Some ED guidelines recommend no treatment for even very high BP’s as long as no evidence of end-organ dysfunction exists, and prompt primary care follow up can be expected.
> 
> With that in mind, and considering that hypertension should almost never be treated prehospital anyway, I can’t think of any reason for a BLS crew to decline a transport based on a BP alone.


You guys all need to have a chat with my department haha


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## CCCSD (May 2, 2019)

Patent pending over 300 is my rule...


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## DrParasite (May 3, 2019)

300/250 might get me to request ALS.....

But realistically, isolated hypertension is a BLS call.  No need for a paramedic, unless there are other symptom.  Could they stroke out?  could they have a cardiac issue?  could they have just been hit by a truck?  yep; however, if they are having no signs of any of these complaints, what is a paramedic going to do?  Most won't treat isolated HTN, without any other signs or symptoms.



teufulhund said:


> Unfortunately a lot of my coworkers will deny calls due to a high blood pressure, even if the call is just a discharge to a SNF.


What is your company policy on acceptable blood pressures?  Do you have management guidelines as to when you can deny patient's due to patient condition?

If the BP is high enough to worry your coworkers, but the MD who is discharging them is ok with it, what is the issue?  the patient is stable enough to go to a SNF, and if they crash during the transport, either return to the sending hospital or go to the nearest ED.


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## johnrsemt (May 7, 2019)

Medics can't do much for HTN unless they have chest pain and give NTG;  or are bad at IV's and bleed the HTN down to lower BP, lol.
if you are headed to the ED, it depends on transport time.  If you can get to the hospital faster than meeting with a medic sanely then do that.  Sanely means:  If you meet the medic a block from the ED, why bother?  What is the medic going to do in a block?  and I have done that a few times, I would climb on the truck with a LP12 and transport and have a 12 lead done.  cause there is no time to do anything else


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## rescue1 (May 7, 2019)

Asymptomatic hypertension, at any number (ANY NUMBER), is not an emergency. You can take them in BLS, you can roll them to the ED in a barrel, you can have them take a taxi. ALS is probably the most dangerous way to transport these patients because they might be tempted to treat the patient (I'm kidding...mostly). The vast majority of these patients will only need oral medicines and follow up with their primary care doctor, as @Remi said. 


Even symptomatic hypertension (which I'm limiting to mostly altered mental status or CVA) rarely needs to be treated prehospitally, unless you have very long transport times (and even then, maybe not). There are exceptions, of course, heart failure and suspected aortic dissection should be treated quickly and aggressively but most people don't lump them into the same category as "hypertensive emergency". 

Anything else is best lowered slowly over several hours, not quickly in the back of the ambulance. You will not do a stroke patient any good by dropping their pressure from 220/140 to 160/90 in 10 minutes. To clarify, I'm not saying that stroke and hypertensive AMS patients should be BLS, but I'm saying that I doubt there's a difference in patient outcomes between BLS and ALS if the transport time is reasonable.


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## DrParasite (May 8, 2019)

As someone once told me, asymptomatic HTN is usually a symptom of another problem, so fixing the symptom rarely resolves the underlying issue; in fact, it can make things worse.

These people need to go to the hospital so a doctor (likely a cardiologist) can investigate why their pressure is higher than usual.  most of the time need a medication adjustment; maybe they are having a heart related issue that needs surgical intervention, maybe it's something else.

But yeah, is ALS just administers NTG, the patient might feel better in the short term, but it isn't coming close to treating the cause of the HTN


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## rescue1 (May 8, 2019)

DrParasite said:


> But yeah, is ALS just administers NTG, the patient might feel better in the short term, but it isn't coming close to treating the cause of the HTN



They might feel worse too--your body gets used to a certain blood pressure (say a chronically non-compliant patient with a pressure of 200/110), and the rapid drop from giving an antihypertensive can cause hypoperfusion of the brain and make the patient altered, give them a headache, and in the worst case scenario, cause a stroke or a demand MI. This issue isn't limited to paramedics--doctors make this mistake all the time, and some new data is suggesting that aggressive BP control in the hospital is associated with worse outcomes because we're basically treating the BP numbers to make ourselves feel better rather than treating the patient. 

Basically, it takes most patients years to crank their BP up to those crazy levels, and you (or a doctor, or anyone) aren't going to fix that kind of damage in a matter of days, barring some very rare diagnoses.


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## RocketMedic (May 18, 2019)

Remi said:


> Some ED guidelines recommend no treatment for even very high BP’s as long as no evidence of end-organ dysfunction exists, and prompt primary care follow up can be expected.
> 
> With that in mind, and considering that hypertension should almost never be treated prehospital anyway, I can’t think of any reason for a BLS crew to decline a transport based on a BP alone.



One of my biggest questions with aggressive EMS is why everyone thinks “we just need to lower that pressure” and tosses in nitrates, beta blockers, etc. if they’re still asymptomatic. Like...184/100 isn’t healthy, but that mild headache doesn’t necessarily mean labatelol.


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## E tank (May 18, 2019)

RocketMedic said:


> One of my biggest questions with aggressive EMS is why everyone thinks “we just need to lower that pressure” and tosses in nitrates, beta blockers, etc. if they’re still asymptomatic. Like...184/100 isn’t healthy, but that mild headache doesn’t necessarily mean labatelol.


 
Mostly agree...unless the HR is up. Then endocardial ischemia becomes a player.


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