Lasix pre-med control

[KellyBracket]

... 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?

 

[Aprz]

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.

 

[Handsome Robb]

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.

 

[Clare]

Clare said it perfectly.

Why thank you, I do try

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

 

[VFlutter]

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.

 

[Clare]

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.

 

[KellyBracket]

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!

 

[Christopher]

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.

 

[Aprz]

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.

 

[Farmer2DO]

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

And Lasix!

Just kidding.....