Just Plain Ruff Posted January 24, 2009 Posted January 24, 2009 Can anyone quote me their protocol for hypertensive crisis. I just ran one, initial blood pressure 249/175 pulse 128 headache cough I went thru our protocols and found that we do not have a hypertensive crisis protocol. By the way the guy was also in CHF and having a MI to boot. Elevation in leads v1-v5
Mateo_1387 Posted January 24, 2009 Posted January 24, 2009 Ruff, our hypertensive protocol allows for either nitroglycerin administration or Labetelol IVP. 20mg of Labetelol is our dosage. Sounds like you guy would already be getting nitroglycerin which may help with the pressure, and in the presence of an MI, a betablocker would not be a bad choice.
spenac Posted January 24, 2009 Posted January 24, 2009 Ruff, our hypertensive protocol allows for either nitroglycerin administration or Labetelol IVP. 20mg of Labetelol is our dosage. Sounds like you guy would already be getting nitroglycerin which may help with the pressure, and in the presence of an MI, a betablocker would not be a bad choice. Nitro is losing favor as it can drop pressure to fast.
spenac Posted January 24, 2009 Posted January 24, 2009 Description: Random treatment of hypertension is generally not indicated in the prehospital arena. A complete assessment must be performed on each hypertensive patient to rule out possibility of a stroke or CVA. Treatment of hypertension must be reserved for patients who are actually having a potential life threat from hypertension and experiencing serious signs and symptoms. REQUIRED ASSESSMENT Check Level of consciousness AIRWAY PATENT? No: Make immediate correction to provide airway!! BREATHING ADEQUATE? No: Provide appropriate oxygenation assistance. CIRCULATION PRESENT? No: Begin Cardiopulmonary Resuscitation. COMPLETE VITAL SIGNS. Blood pressure, pulse, respirations, pulse oximetry. HEAD TO TOE EXAM Protocol specific assessment IF PATIENT IS EXPERIENCING STROKE SYMPTOMS, MOVE TO THE CVA PROTOCOL FOR TREATMENT. DO NOT REDUCE PRESSURE IN CVA PT! Treatment of patients should be reserved for those with signs and/or symptoms of HTN including: Headache, visual disturbance and/or nose bleed. Hypertension includes patients with a Systolic of >140 and Diastolic >90. However, prehospital treatment should be limited to patients with a systolic pressure of >180 and/or Diastolic >100. Patients with a systolic of >220 and/or diastolic >140 should be treated in the absence of symptoms. If patient is pregnant, refer to OB protocols. NIBP should not be used as the sole source of vital signs if medications are going to be used to reduce blood pressure. DO NOT ATTEMPT TO REDUCE PRESSURE GREATER THAN 30% OF INITIAL READING! Basic treatment guidelines Administer oxygen appropriate to patient condition Transport patient to the closest hospital appropriate for condition. Intermediate treatment guidelines Intubate if necessary for airway control Establish IV of Normal Saline, rate appropriate to condition Administer Nitroglycerin 0.4 mg SL. May repeat x3. Paramedic treatment options If patient has a history of asthma, congestive heart failure or diabetes, administer Enalapril 1.25 mg SIVP. Do not repeat. (Do not administer in Black Males. Move to Labetalol.) All other patients administer Labetalol 5 mg SIVP. May repeat every 5 minutes to a total dose of 20 mg. Consider Promethazine 12.5 mg SIVP or 25 mg IM for nausea. May repeat x1 in 10 minutes if no response. Advanced paramedic treatment options Rapid Sequence Induction Intubation as needed for airway control.
crotchitymedic1986 Posted January 24, 2009 Posted January 24, 2009 Funny, I remember all those patients I treated with a squirt of procardia under the tongue, not a single complication. I think the pointy-headed ACLS faculty have overthought this one.
CTXMEDIC Posted January 24, 2009 Posted January 24, 2009 Nitro is losing favor as it can drop pressure to fast. Which is why those 60gtt sets are so nifty... :roll: Our protocols call for: Nitro drip Lopressor 5mg Q5min for max of 15mg labetelol 20mg prn q10min as 40mg for max of 300mg
mobey Posted January 24, 2009 Posted January 24, 2009 Funny, I remember all those patients I treated with a squirt of procardia under the tongue, not a single complication. I think the pointy-headed ACLS faculty have overthought this one. I don't really see how switching from Calcium channel blockers to B Blockers is anymore complicated? Ca blockers have become second line drugs for the most part. Adalat specifically is second line to B-Blockers and Nitro. 'Round here Ca Adalat is used almost exclusively for chronic stable angina..... and yes HTN when B-Blocker contraindications are met. I would go with Metoprolol and Nitro
crotchitymedic1986 Posted January 24, 2009 Posted January 24, 2009 I have no problem with the other meds listed. I was aiming more at those that have NO protocol for treating hypertension in the absence of any other symptom. Cant tell you how many times EMS brought a patient to the ER with B/P of 280/140 or higher with no treatment, because they didnt have a protocol. And I am not talking about people who have a pressure of like 200/100 --- but in the extremes above that, we should be treating.
akroeze Posted January 24, 2009 Posted January 24, 2009 I don't have any protocol for it and that has been a problem to me from day one. The two things that bother me most about my cardiac care options is I have nothing for rate control and nothing to bring pressure down. Sure I have Nitro but that is pretty much playing with fire and I don't know if the doc would be for it anyway since it would be SL spray and not a drip
paramedicmike Posted January 24, 2009 Posted January 24, 2009 Treating the pressure depends on the cause. Too much, too soon, too fast and suddenly that HTN patient just turned into a hypotensive puddle or worse. If you're not careful you wind up hypoperfusing the brain. Depending on the cause of the hypertension you've just added the insult of hypoperfusion to an already injured brain. Technically, I can treat HTN (stroke or TBI related) if the pressure is greater than 220 systolic and greater than 120 diastolic. My choices, depending on other factors, are labetalol or hydralazine. But even if I choose to treat the HTN I can only drop their systolic pressure by 10% and need to maintain a close eye on their MAPs. For something like CHF related HTN it's CPAP, NTG and we just recently started using ACE inhibitors. For pre-eclamptic/eclamptic patients it's Mag Sulfate. We may see some changes in the near future with regards to head injuries and HTN but it won't be anything drastic. -be safe
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