Pain Management + unresponsive patient

[TheLocalMedic]

Had a hypertensive crisis this evening. Younger guy with a history of BP spikes, taking metoprolol and called for a headache, dizziness and nausea. Pressure was over 250 systolic.

Called in for an order for nitro (because we don't carry any beta blockers) and got denied by base. I painted as clear a picture as I could, but they just shut me down. GRRRRRRRRR.... I asked to speak with the doc afterwards and she wouldn't give me the time of day. I think I've been in EMS since before she even started med school, but...

I even explained to her that when I call in for orders that I'm not so much asking for permission as telling them what I plan to do and following our "protocols" by contacting base first, but got stonewalled...

 

[jefftherealmccoy]

Ever heard of rebound/reflex hypertension with nitro? Or seen it?

A little counterproductive for those patients in a hypertensive crisis.

We carry metoprolol but have no protocol for it except for STEMI patients who meet certain parameters. Medics call for orders for it though all the time and get them.

Heard of it. Never seen it. I figured that the nitro/morphine combo is just a quick fix until we can get the pt to the ED and get them some more long term treatment. If we had beta blockers, I'd use 'em. Until we get 'em, I'll use what we got.

 

[Melclin]

From what I've heard from the ED staff is that they prefer opiates over benzos because they can reverse the opiates with narcan. I've yet to see when benzos (valium and versed) have tanked a blood pressure, but I've seen a few times in my short career where opiates have. I know it's a possiblility with both, but is it truly more likely with benzos than opiates?

While I do feel morphine is safer than a benzo, the opiate/benzo at equivalent doses (whatever that means) argument was perhaps not one I should have mentioned as it isn't really important to my point and it seems to have confused things. Additionally the type of patient you mention is not the kind of patient I was talking about. I don't quite understand why this has required so much discussion to clarify; maybe I haven't made myself clear. Maybe I shouldn't post on contentious issues when I've had a few beers.

Again: In the patient with both a head injury and an obvious pain producing injury, who is agitated and resisting your attempts to do the necessaries, I'd suggest that people consider the possibility that pain may be playing a role in their agitation. If you treat their pain directly it may take, relatively speaking, less of an analgesic than a sedative (and hopefully haemodynamically safer, with less affect on their conscious state if that is a concern) and it seems intuitively to be a more humane option. This is a treatment I've used and seen used with apparent success and one I'm fond of, so I thought I'd mention it.

I would agree that the risk of serious hypotension from opioids is quite overstated, but it does happen, especially with morphine. Especially in a volume depleted patient, or one with myocardial depression.

It won't happen with the 2-5 mg doses that are commonly used in EMS, but once you get very far north of 10mg or so - which is the kind of dose you need to have any real sedating affect on an agitated patient - you can drop the BP pretty significantly.

Versed can drop pressure too, if they are volume depleted and SNS-dependent.

I suppose if I had to reverse something, I'd rather reverse an opioid OD than a benzo OD, but I think it's best to use drugs the way they are meant. Sedative meds are for sedation, pain meds are for pain.

You'd need to give an awful lot of either drug to require reversal......

Bolded for emphasis, because it goes to heart of my original argument. I really had not meant to create a "benzos Vs opiates for sedation: which is safer" kind of debate. My point was to consider treating the underlying problem and to consider that pain may play a role in the agitation of certain patients.

I agree. I've seen opiates tank a blood pressure. I dropped a pt's BP substantially with just 2mg morphine. I have yet to see benzos tank a blood pressure. I'm not saying it isn't going to happen, I'm just not inclined to say that benzos are more likely to tank a blood pressure than opiates, specifically morphine. Again, I've not been doing this as long as most of the people here, so I could very quickly change my mind about that.

We use morphine specifically for hypertensive crisis, we don't use benzos. I took this as the drug that is more likely to cause a drop in BP to be morphine. Am I wrong?

Yep, didn't deny morph can, especially in certain patients (I did specifically mention the added risk in volume depleted patients).

RE the hypertensive crisis stuff, I think thats probably faulty logic. I don't think its as simple as one drug being the most likely to cause hypotension.

 

[MountainMedic]

no Labetalol? I have never heard of morphine as a first like treatment for hypertension. I can understand the morphine/nitro in pulmonary edema but there are so many better options for hypertensive crisis.

Labetalol? Doesn't that last for up to 12h? Metoprolol and esmolol FTW.

 

[KellyBracket]

Had a hypertensive crisis this evening. Younger guy with a history of BP spikes, taking metoprolol and called for a headache, dizziness and nausea. Pressure was over 250 systolic.

Called in for an order for nitro (because we don't carry any beta blockers) and got denied by base. I painted as clear a picture as I could, but they just shut me down. GRRRRRRRRR.... I asked to speak with the doc afterwards and she wouldn't give me the time of day. I think I've been in EMS since before she even started med school, but...

I even explained to her that when I call in for orders that I'm not so much asking for permission as telling them what I plan to do and following our "protocols" by contacting base first, but got stonewalled...

Just wondering - why did you feel so strongly about lowering this patient's BP? That is to say, what were you trying to prevent by dropping the BP?

(This is pretty off-topic, I realize.)

 

[Carlos Danger]

Labetalol? Doesn't that last for up to 12h? Metoprolol and esmolol FTW.

IV is more like 2-3 hours.

Commonly used for hypertensive crisis.

 

[Handsome Robb]

IV is more like 2-3 hours.

Commonly used for hypertensive crisis.

Seems like either metoprolol or labetalol in the emergency setting.

All I've ever seen used at least.

 

[VFlutter]

Seems like either metoprolol or labetalol in the emergency setting.

All I've ever seen used at least.

Hydralazine IV also works well for patients who are Beta Blocker intolerant.

 

[Handsome Robb]

Hydralazine IV also works well for patients who are Beta Blocker intolerant.

Touché sir. Also seen that used as well but not nearly as often.