Treating Hypertension

[Akulahawk]

Another concern: this person is going straight to surgery, maybe a quick ultrasound at the receiving door. What do your surgeon and anesthesiologist want? Be a bummer to get the pt there with vital signs, but the op fails because of pharmacy or spoiled venous access.

Any protocols ought to include the receiving facilities' input, and once adopted all receiving facilities need to know what they will receive..then prehospital techs need to follow them.

I didn't think a vasodilator would directly change a central major vessel, they are actually vaso-relaxers, right? Major vessels don't experience the neuro-muscular vasoconstriction peripheral vessels do. Plus in us old calcified specimens, they're pretty non-flexible to begin with.

Mycrofft... you're a dinosaur, not a fossil... You're not quite that calcified.

Anyway, something like this could simply be a protocol to contact the BHP and get a destination and treatment orders and have the various receiving facilities come up with what they want done in the field for initial treatment of a dissecting aorta, and what they'd like done to expedite the patient to the OR.

While such a protocol may have a "mother may I" feel to it, that would also allow the receiving facilities to try different field care ideas in a more flexible manner while allowing for consistency.

 

[Wheel]

Mycrofft... you're a dinosaur, not a fossil... You're not quite that calcified.

Anyway, something like this could simply be a protocol to contact the BHP and get a destination and treatment orders and have the various receiving facilities come up with what they want done in the field for initial treatment of a dissecting aorta, and what they'd like done to expedite the patient to the OR.

While such a protocol may have a "mother may I" feel to it, that would also allow the receiving facilities to try different field care ideas in a more flexible manner while allowing for consistency.

I would certainly contact a doc with this, present my findings and concerns along with a proposed treatment plan (nitro tabs and paste and narcs would be my only options.) Then we make a plan and go for it, and I advise of any changes in patient condition. I don't want to cowboy a situation like this when I can consult with the person who will be taking over care of this patient after my short ride with them.

That's not to say be a cookbook medic and pawn the decision off to a doc. This is a great opportunity to be a patient advocate and prove to your receiving facility that you aren't a moron.

 

[mycrofft]

Addressing the aneurysm before it dissects (Oxford Journal):

http://cardiovascres.oxfordjournals.org/content/83/3/436.long

http://cardiovascres.oxfordjournals.org/content/83/3/436/F1.medium.gif

MEDSCAPE ARTICLE (prehospital dissecting aoritc aneuryms or DAA):

http://emedicine.medscape.com/article/756835-overview#aw2aab6b3

MEDSCAPE defintive tx: http://emedicine.medscape.com/article/756835-overview#aw2aab6b4

AND I QUOTE: "Long-term medical therapy involves a beta-adrenergic blocker combined with other antihypertensive medications. Avoid antihypertensives (eg, hydralazine, minoxidil) that produce a hyperdynamic response that would increase dP/dt (ie, alter the duration of P or T waves)".

EMED:

http://www.fjac.com/links/aorticdissection/eMedicineDissectionAortic.htm

AND I QUOTE: Nitroprusside (Nitropress) -- Causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. Commonly used IV because of rapid onset and short duration of action. Easily titratable to reach desired effect. Light sensitive; both bottle and tubing should be wrapped in aluminum foil. Prior to initiating nitroprusside, administer beta-blocker to counteract physiologic response of reflex tachycardia that occurs when nitroprusside used alone. This physiologic response will increase shear forces against aortic wall, thus increasing dP/dT. Objective is to keep heart rate at 60-80 bpm".

Last, medicines and DAA:

http://cdn.intechopen.com/pdfs/1691...aortic_aneurysms_ruptures_and_dissections.pdf

 

[jwk]

Anxiolytic, pain control, and reduced MVO2, primarily. I don't carry any antihypertensives, so I can do my best to help the body control itself all on it's own.



With a pressure like that, MS would most likely be my first choice as well.

No antihypertensives available? That seems strange. I would have thought that would be pretty standard. We carried them 30 years ago.

 

[jwk]

The whole goal of therapy in a dissecting aneurysm is reduction of aortic wall tension, which requires reduction of both HR and MAP.

Analgesia alone is likely not enough, though fentanyl in large enough doses is a good sympatholytic.

Labetolol is an OK choice. Esmolol is better, IMO. Nitrates are fine but are usually given with a beta blocker in order to reduce chronotropy.

There are different protocols out there, but a common goal is an SBP of 120 or less and a HR 60-70.

I once transported a patient with a dissection who had been intubated so that he could go on a propofol drip because of intractable pain and hypertension. I don't remember what all they tried before the propofol, but he was on a large dose of it as well as nitrates and beta blockers.

To me, esmolol is a lot like labetalol with a much shorter duration of action. Titrate the doses and it's hard to get into trouble.

Labetalol is a great drug, but easy to overshoot the effect you're looking for if you start out with big doses.

Metoprolol is OK, but the onset is somewhat longer and once it's in, it's not wearing off any time soon.

Analgesia is fine - but may not help in this situation.

Propofol is not used as an antihypertensive, although it will certainly knock down a blood pressure, particularly with a bolus dose. A non-sedated non-paralyzed patient is not going to do well with an ETT, regardless of their underlying pathology. Sure, their pressure may come down simply by being sedated some, but that still doesn't make it an antihypertensive.

 

[TransportJockey]

No antihypertensives available? That seems strange. I would have thought that would be pretty standard. We carried them 30 years ago.

Nope. It's one of the few areas NM is behind on. When I worked in Texas we carried metoprolol. Here in NM, NTG is the only med I carry that could be used as such but all we carry are tabs. We are supposed to be getting paste as well and the rumor with the new state scope of practice is that we will possibly be getting beta blockers for something other than transport only meds.

 

[Rialaigh]

From the minimal research I have done on hypertension prehospitally and in the ER setting, I just don't see a justification for having the benefit outweigh the potential risks of attempting to treat in the field at all.

Many progressive ER doctors will send patients home with a BP of 230/150, because they are in hypertensive urgency, which is entirely different from hypertensive emergency (or crisis). I would be very careful dropping the BP on anyone who has any neuro symptoms at all, I would be careful dropping the BP on dialysis patients or anyone with impaired kidney function. I just don't see that us taking a shot at correcting hypertension in the field on transports of less than an hour is worth anything at all.

maybe one of our forum physicians could enlighten me with some research or studies showing benefit to rapid reduction of BP in any conditions that are "diagnosable" in the field.

 

[Carlos Danger]

From the minimal research I have done on hypertension prehospitally and in the ER setting, I just don't see a justification for having the benefit outweigh the potential risks of attempting to treat in the field at all.

Many progressive ER doctors will send patients home with a BP of 230/150, because they are in hypertensive urgency, which is entirely different from hypertensive emergency (or crisis). I would be very careful dropping the BP on anyone who has any neuro symptoms at all, I would be careful dropping the BP on dialysis patients or anyone with impaired kidney function. I just don't see that us taking a shot at correcting hypertension in the field on transports of less than an hour is worth anything at all.

maybe one of our forum physicians could enlighten me with some research or studies showing benefit to rapid reduction of BP in any conditions that are "diagnosable" in the field.

I think you are correct in general about not attempting to treat hypertension - even severe hypertension - prehospitally. There is just too much to it, and very often the patient has been that way for days or weeks or longer, and it simply isn't emergent.

However, if a leaking aortic dissection is present along with severe hypertension, you have a hypertensive emergency of the highest order. In that case I think it is very appropriate to attempt to bring the BP and HR down some, providing you have the means to do so.

But to be honest, I don't know what the literature says. Perhaps there have been studies done on prehospital management of BP during aortic dissection that show it actually isn't beneficial. Maybe someone here has the time to look into it.

 

[Rialaigh]

I think you are correct in general about not attempting to treat hypertension - even severe hypertension - prehospitally. There is just too much to it, and very often the patient has been that way for days or weeks or longer, and it simply isn't emergent.

However, if a leaking aortic dissection is present along with severe hypertension, you have a hypertensive emergency of the highest order. In that case I think it is very appropriate to attempt to bring the BP and HR down some, providing you have the means to do so.

But to be honest, I don't know what the literature says. Perhaps there have been studies done on prehospital management of BP during aortic dissection that show it actually isn't beneficial. Maybe someone here has the time to look into it.

I'm all about this if it is evidence based. However based on all the EMS "education" issues I would think it would result in many many many people getting unneeded medication possibly resulting in poor brain perfusion or even hypotensive crisis with inadequate MAP. I just don't think we have the education and experience to try and medicate this very small patient population properly unless someone can come up with a set of rules or a scoring index that would indicate medicating based upon a physical exam and history,

Id love to see if there is a study out there, I may do some looking later tonight.