Hypertension

[triemal04]

I wouldn't go so far as to say don't treat the patient at all; I'd be comfortable in calling this hypertensive encephalopathy.

The first line should have been the narcotic of your choice, both for the headache, and for any associated anxiety, but if the symptoms persisted after an appropriate dose without change and N/V still developed...I think treatement is warranted.

Esmolol might be the better choice, especially prehospital, just due to it's quick onset and short duration, but as long as it was remembered that reaching a "normal" BP is not the goal (25% reduction in MAP at the most) and that it doesn't need to be instantaneous...I say treat this one.

Edit: medscape has some good articles on hypertensive emergencies/encephalopathy

http://emedicine.medscape.com/article/1952052-overview#showall

http://emedicine.medscape.com/article/166129-overview

Edited January 18, 2015 by triemal04

[systemet]

The problem with these case presentations, is we each imagine a slightly different patient. I look at this and see someone hypertensive, with some mildly concerning symptoms; headache, dizziness, proteinuria, and you see the beginnings of hypertensive encephalopathy. We may both be right, but we're just visualising different patients. It's really hard to talk in hypotheticals.

I think the analgesia for the headache is a little problematic here, and the best agent probably depends on the severity of the pain. If it is severe and debilitating, some morphine might be a reasonable choice, but runs the risk of obscuring the initial neuro exam, complicating and worsening any change in level of consciousness, and causing a rebound effect. Most headache situations I tend to opt for toradol, but with this hypertension, and the ACE inhibitor, there's got to be some concern about renal function, which means toradol probably isn't the best choice either. I think if you're going to treat, small aliquots of morphine might be the best.

If we were to attempt to reduce MAP, labetalol seems like a good option, as you've got some alpha effects there too. I think there's got to be some respect for the history of reactive airway disease in this patient if we're going to give a better blocker, though. In years gone by, we gave nicardipine (adalat), but created some spectacular messes, as it tended to be a little unpredictable. I'm not sure what the best practice is here (hopefully ERDoc can educate us), but based on what I have available on my ambulance, if we treated, I'd expect to get orders for some IV nitroglycerin, maybe with some metoprolol to block any reflex tachycardia.

[ERDoc]

I agree with systemet, I think we all have a different picture of what this pt looks like. I would not be very aggressive with treating the BP, especially in the field. There is no urgent need to fix it, especially since we don't know what the pt normally runs. This could be her normal for the last few months and dropping it precipitously will cause problems. She certainly needs evaluation for end organ damage in the ER, but I think from the field perspective your best bet is to monitor and transport. Treating her headache wouldn't be a bad idea. I would avoid toradol because she has a motrin allergy and because we haven't ruled out a bleed yet. Otherwise, it would be appropriate. Morphine would be fine. I would give this woman an extra dose of her lisinopril and work her up. If we get her feeling better and there is no end organ issues, I would call the PMD and see what he wants to adjust. If there is end organ damage, obviously we will need to up our game a bit.

[triemal04]

Fair enough. I'm looking at this and envisioning someone in more distress though the onset of of vomiting and her history is still concerning to me.

[island emt]

We could use leeches to bleed her pressure down a bit

[ERDoc]

Phlebotomy is an accepted treatment for polycythemia vera.

[island emt]

Then it's good that I kept a jar of giant Okinawa tree leeches from when I was stationed there.

[Levi]

I'd be cautious about treating someone's blood pressure before a definitive diagnosis of a hypertensive urgency/emergency, and ruling out alternatives like a hemorrhagic or ischemic stroke. Even then, you are aiming for a 10-20% max reduction in the MAP over the first hour which might be difficult to do outside of an ICU or stepdown environment. I agree with treating the nausea and pain first and then reassessing blood pressure afterwards.

[hertzvanrental]

Iv paracetamol (or morphine titrated to effect) and Ondansetron for symptom relief. Monitor and transport. Avoid nitro, dangerous and outdated practice with regards to managing HTN in the field. You've got no control. What is the rationale for treating HTN in the field?

[1EMT-P]

What is your rationale for wanting to only monitor this patient? She has an extensive medical history & is at high risk for organ damage. Plus she has been evaluated by her PCP who has determined that her BP is well above her normal baseline.

What is your rationale for wanting to give Morphine to this patient? The indications for Morphine are 1. Severe Acute Pain. 2. Moderate to Severe Chronic Pain. 3. Pulmonary Edema & 4. Pain Associated with MI according Davis Drug Guide. If you give this patient Morphine you potentially risk causing altered mental status, dizziness, headache, hypotension, impaired neuro exam, nausea, respiratory depression & vomiting. Plus Increased ICP is a concern.