Hypertension in anxiety attacks?

[Maine iac]

Had a call for diff. breathing today. 10 year old male found hyperventilating and complaining of rib pain. Pretty clear cut anxiety (which he and mum confirmed) and hyperventilating. Once breathing was controlled the pain and complaint disappeared.

His vitals were normal except his BP was high. Palped BP in the 160s, so osculated a bp of 168/110, and a few minutes later got another reading of 158/108.

I was wanting to not transport the kid (save parents a bill, their time, and once he calmed down he was normal and playing/joking around with us) but I couldn't say his vitals were normal and my partner was also a little confused with the high BP reading so we transported.

Is this common of an anxiety attack or of somebody hyperventilating to have a high BP?

 

[the_negro_puppy]

http://www.medscape.com/viewarticle/407702

apers in the medical and psychiatric literature state that hyperventilation causes vasoconstriction and increases of blood pressure, even though a classic early study of the hemodynamic effects of voluntary hyperventilation concluded that hyperventilating for one minute lowered peripheral resistance by 45%, and mean blood pressure by 23 mm Hg.[3] So, who is right? The answer is possibly both. A recent study of the effects of hyperventilation compared the blood pressure and heart rate changes in patients with panic disorder and normal controls.[4] In the normal subjects both systolic and diastolic pressure decreased, while in the panic patients both systolic and diastolic increased. In addition, about one third of the panic patients reported symptoms of panic during hyperventilation, whereas none of the controls reported symptoms. The explanation may be that hyperventilation itself does lower blood pressure, and it is only when panic is superimposed that the pressure goes up.

 

[Shishkabob]

Hyperventilation = blow off of CO2 = alkalosis

Chemo receptors and catecholamines and vessels and stuff and words.

 

[zmedic]

Was this kid obese? Just out of curiosity.

That aside, the kid should get a repeat BP measurement in like 30-60 minutes to see if that reading is real. Now I know it looks bad to not transport that kid. So I would use the power of verbal judo, ie getting the patient to do what you want by using the proper words, while still covering your butt. How I would approach it is to say

"your son looks like he's doing well but his blood pressure is high, I can't say if this is due to the anxiety but I think he should be evaluated by a doctor. We are happy to take you guys to the hospital. If you don't want to do that you have a couple of options, you can call his doctor now and see what they want to do, you can drive him to the hospital yourself, or you can take him to his doctor (if during the day), it's up to you. You don't want to go in the ambulance? Okay, sign this paperwork. I have to tell you in the worst case scenario by delaying his evaluation he could have a seizure, have worsening of his condition, coma or even death. Any questions?"

A lot of people don't know that they have the option of signing AMA and seeing their own doctor. Now if you want the patient to go to the hospital you don't even bring it up, you just say get in the rig. But by making clear you are happy to take the patient, and it is their (or their parent's choice), and signing the AMA you've covered yourself well. To even finish it off I've offered to have the patient call their doctor (if during the day) and have their doc agree to see them before they sign the AMA a leave. I've had good success with this approach.

 

[Shishkabob]

you can call his doctor now and see what they want to do,

Just wastes everyones time.


They will always, ALWAYS say "Call 911 and take the ambulance to the hospital". Always, and without fail. Might as well save them the minutes on their cell phone plan and tell them to hop in the truck, as that's always going to be the end result if they call their doctor and say the ambulance is already there.

 

[bigbaldguy]

Just wastes everyones time.


They will always, ALWAYS say "Call 911 and take the ambulance to the hospital". Always, and without fail. Might as well save them the minutes on their cell phone plan and tell them to hop in the truck, as that's always going to be the end result if they call their doctor and say the ambulance is already there.

I have to agree. The odds of a doctor putting his neck out in a situation like this are pretty long.

 

[Chris07]

An anxiety attack can cause a sympathetic response (psychogenic shock), so I wouldn't be surprised to see some hypertension. Also, the low CO2 level from the kid's rapid breathing most likely compounded that effect.

My question now is: Is this kid prone to anxiety attacks? (If that is indeed what he was experiencing) Does he have a panic disorder? If this is the first time anything like this has happened, I would really like the kid to get evaluated. I wouldn't beg for the kid to go to the ED, but I definitely wouldn't mind it. Maybe I'm being paranoid, but if this has never happened before I'm slightly concerned this kid has a neuro issue of some sort, might explain the HTN...but most likely not. Assuming a clean SAMPLE, that's all I have to work with (assuming it wasn't simply anxiety). That's my basic opinion

 

[medichopeful]

Is this common of an anxiety attack or of somebody hyperventilating to have a high BP?

A panic attack leads to stimulation of the SNS (the "fight or flight" system), which leads to the release of catecholamines (epinephrine, norepinephrine, dopamine) into the system. These cause vasoconstriction in some parts of the system, which leads to an increase in BP.

I'm not too sure about respiratory alkalosis (from overexhaling CO2) causing increased BP. If I had time I'd look but I should be doing my care plans!

 

[DrankTheKoolaid]

An anxiety attack can cause a sympathetic response (psychogenic shock), so I wouldn't be surprised to see some hypertension.

You have that backwards. Psychogenic shock causes vasodilation and a relative hypovolemic state causing the brief loss of consciousness

 

[zmedic]

I have to agree. The odds of a doctor putting his neck out in a situation like this are pretty long.

I've had success with this in the field. Especially when the patient is on the fence about what they should do. You can't really recommend not taking them to the hospital. It's just something to keep in your bag of tricks. I usually say "or you can go to your doctor or have someone drive you to the hospital if you don't want to go in the ambulance," lots of people are fine with those options.

I think the 10 minute phone call is worth it if you think you'll be able to get back in service rather than spend half an hour transporting.

 

[bstone]

Hyperventilation usually does a poor job of "blowing off" CO2 because there is little to no gaseous exchange occurring. CO2 then binds with H2O and forms H2CO3 in the CSF, which then gives off H+ ions, then the central chemoreceptor in the medulla senses a fall in pH, leading to acidosis.

 

[Chris07]

Well psychogenic shock was probably a bad term to use! :wacko:

The point being that anxiety attack causes a sympathetic response which in turn causes an increased BP.

The term I wanted to use was Acute Stress Response...but it was my belief that that was the same as psychogenic shock. Is that incorrect?

 

[Shishkabob]

An anxiety attack can cause a sympathetic response (psychogenic shock), so I wouldn't be surprised to see some hypertension.

Shock + hypertension. Does not compute?

Hyperventilation usually does a poor job of "blowing off" CO2 because there is little to no gaseous exchange occurring.

That's IF they are having shallow ventilations in the first place, which in all the 'panic attacks' I've seen, they are at no disadvantage of normal or deep ventilations, leading to the 'textbook' carpal pedal spasms.


But without the OP stating "rapid but deep" or "rapid and shallow", no way to tell.

 

[Maine iac]

The kid was not obese, normal 10 year old (maybe plus 10lbs), leaning back on a couch breathing fast and fairly deep. He was quite anxious, and a little tearful. First thing I did was get the kid to slow down and work on his breathing. As soon as things began to normalize we walked him out to the ambulance and kept chatting with him.

He said he was feeling nervous/anxious, and I think his home life was being a little difficult at the moment. But as soon as he was out in our ambulance he calmed right down and was a normal 10 year old again.

Zmedic, I did pretty much what you said, I told them that the kid seemed to be checking out good (except I couldn't say his BP was good), we were able to identify a probable cause for his breathing, and put the offer out for a transport which they said they wanted so off to the hospital we went.

I've got short transport times for the most part since I'm in a larger city.


I figured the bp could be raised through the same process that many of you have said, but I was just a little taken back at it being that high.

 

[mycrofft]

Sidetracking the physiologic question:

Not necessarily with this pt, but turn it around:

What besides "anxiety" would raise BP AND cause a SUBJECTIVE sensation of chest pain, anxiety and shortness of breath?(in other words, anxiety as a symptom/sign, not a diagnosis) in a child.

Was pulse regular, or irregularly/regularly irregular, strong, weak? Chest clear? Chest tender to palp? Any EKG done? Did pt control breathing quickly after EMS on scene?

That aside, hyperventilation can be a conscious or subconscious attention-getting or power-asserting maneuver. Maybe you actually helped diagnose a hypertension pt even if the call was for a supratentorial problem, good one (?).

And one question looking kid dead in the eye: "DId you get ito your parents' drugs or medicine?".:wacko:

 

[Arovetli]

There is some seemingly conflicting information in the thread and it is important to note that both acidosis and alkalosis can be induced by abnormal respirations.

It's a bit difficult to fully explain without mathematics and a grounding in chemistry. Just imagine a complicated equation that normally exists in equilibrium, alterations of a variable (such as increased or decreased CO2) will stress the equation, and the equation will act, or attempt to act, to relieve the stress and go back into equilibrium. For instance increased partial pressure of CO2 at the alveoli can ultimately force what bstone outlined: abnormally high levels of deprotonation ("giving off" of H+).

 

[Arovetli]

There is some seemingly conflicting information in the thread and it is important to note that both acidosis and alkalosis can be induced by abnormal respirations.

Also note that this can be flipped around and abnormal respirations can be induced by acidosis/alkalosis.

It's homeostasis, equilibria, compensation, entropy, Le Chatlier's....whichever term you'd like, but it's just a complex multivariate equation that seeks the lowest energy and the most stable outcome possible. Fluctuations cause all sorts of aberrant things.

And based on the information in the post the differential for hypertension is quite wide but I'm not jumping to any significant pathology. Sounds like a kid with anxiety or acting out or both. Best play is to do what you did: Calm the kid down and offer transport if they'd like.

 

[zmedic]

I'd also point out that this is a very different call if you show up and the mom says "he's never had anything like this before." I'd be a lot more worried about something else, like new onset diabetes, metabolic disorder, pulmonary embolism (unlikely in his age but possible if he has a clotting disorder).

Now not that one should be totally reassured by a past history of something, but when someone says "this breathing feels just like my 42 other asthmas exacerbations, and I feel better after that albuterol," I'm not looking too hard for another reasons. Likewise, when you show up and mom and kid say "this is just like his panic attacks," panic attacks are 1,2 and 3 on by differential for the kid.

 

[bstone]

I asked my physiology professor today about hyperventilation (it's useful that we're doing pulmonary at the moment). He said that most hyperventilation causes a lack of CO2 in the blood, thus raising pH and the patient becomes alkolotic. I asked about the depth of breathing and gaseous exchange and he said that gaseous exchange is happening in hyperventilation. For those who are curious, he's an MD who did a residency in Internal Medicine.

 

[Arovetli]

I asked my physiology professor today about hyperventilation (it's useful that we're doing pulmonary at the moment). He said that most hyperventilation causes a lack of CO2 in the blood, thus raising pH and the patient becomes alkolotic. I asked about the depth of breathing and gaseous exchange and he said that gaseous exchange is happening in hyperventilation. For those who are curious, he's an MD who did a residency in Internal Medicine.

It starts to make sense when you work through the equations. I don't really know how to explain it nonmathematically. Maybe someone else can explain it better. For most people on this forum the nuts and bolts of how this stuff works is probably terribly boring. It is fascinating stuff if your into chemistry.

Carbonic acid is a principal intermediate and if you google it you can probably find a decent overview of the math.

Your always going to have some form of "gas exchange" as long as you have some air and blood movement because the gases will seek out equilibrium. To further muddle things alot of people term tachypnea as "hyperventilation" when you actually have alveolar hypoventilation.

On a side note, EtCO2 monitoring for respiratory distress patients is the way to go.