Hypertensive Emergencies

[MagicTyler]

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?

 

[Carlos Danger]

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"?

 

[abckidsmom]

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?

 

[NomadicMedic]

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.

 

[VFlutter]

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.

 

[TransportJockey]

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.

 

[Rialaigh]

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.

 

[polisciaggie]

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.

 

[Aprz]

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?

 

[usalsfyre]

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.

 

[tacitblue]

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.

 

[tchristifulli]

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.

 

[Carlos Danger]

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.

 

[Handsome Robb]

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.

 

[Akulahawk]

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?

 

[VFlutter]

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.

 

[Merck]

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

Really?

 

[Wheel]

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.

 

[Carlos Danger]

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

Really?

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

 

[Handsome Robb]

Really?

Yes.