Transport priority for hypertensive emergency?

[scratrat]

I had to go and reread the hx. I would transport this pt as a moderate priority. No light and sirens, but a full als work up. It doesn't sound as if she has a SAH going on. Her headache is no longer, she is not nauseated, she is concious, with no blurry vision, and from what I can see she isn't even on coumadin. Diastolic of 160 is very high, I would definately try to lower the BP. Sounds like she popped her top!

You should never be lowering the BP in the field. Maybe in conjuction with an MI, but never any other time. Especially not with an associated H/A, whether it cleared or not. A neurologist will rip you a new one if you do. Until you prove there is no bleed, you definately shouldn't be so damned aggresive on this one.

[JPINFV]

Wouldn't lowering BP by lowering the heart rate be more prudent than vasodilation? Giving nitrates doesn't lower cardiac output, but would make it easier for blood to reach the hemorrhage by making the vessel larger, which would make it easier for more blood to escape.

[AZCEP]

Nitrates will worsen the ischemic prenumbra of the nervous tissue. Careful control over how much you decrease the blood pressure has to be taken. This patient may be a candidate for more aggressive therapy, but until a CT is done you should not aggressively lower the pressure.

A beta blocker would be a decent option for prehospital, if they are available. Nitrates should not be considered for this patient due to the lack of control you would have.

[firefighter523]

What? Hah?..... I guess you could talk to the command doc that gave me orders just the other day to give a pt with the almost exact same complaints, NITRATES. If you would READ , and maybe REREAD the Hx, you could clearly rule out a SAH. The pts head ache went away, how the heck you you expect someone with a very bad head ache associated with a SAB to just all of a sudden go away, her nose started bleeding, and she went complaint free. For the people who believe that you shouldn't lower a pts BP in the field with any complaint associated with a diastolic pressure that high, and you can rule out SAH, ie... no hx of trauma, no more headache after her nose started bleeding (big one folks) and good equal and reactive pupils, and the fact that she has a gcs of 15, you should not be practicing.

Correct me if I am wrong, but if a pt's BP is above 180 systolic, you cant give TPA anyway. You all are making a mountain out of a mole hill. That is just ludacrist, not lowering a BP in the field that is that high!!!

[firefighter523]

AZCEP,

Since when do you have a lack of control giving nitrates???? You give them every 3 to 5 minutes for a reason, because they wear off that fast. :roll: That is why they are the cat's a## in CHF. If there BP crashed, you lay them down, and give them a fluid bolus!! Amazing, isn't it??? All of the time you have to read those books, I am suprised you didn't come across that :shock:

[firefighter523]

JPINFV,

Yes, you would lower the heart rate. Do you know how you would do that?? VASODILITATION. The heart beats faster because it has to pump against an increased vascular resistance, you take that away, the heart says thanks. :?

[firefighter523]

Scratrat,

???????????????The BP thing.............. Start over with the whole paramedic thing, infact go get a job more suitable for yourself, like in a barber shop or something!!!

[AZCEP]

AZCEP,

Since when do you have a lack of control giving nitrates???? You give them every 3 to 5 minutes for a reason, because they wear off that fast. :roll: That is why they are the cat's a## in CHF. If there BP crashed, you lay them down, and give them a fluid bolus!! Amazing, isn't it??? All of the time you have to read those books, I am suprised you didn't come across that :shock:

When did I say anything about not having control in giving them? You have the control of giving 400 micrograms without the ability to titrate the response. If the patient becomes hypotensive, you have to wait the 3-5 minutes before you can give any more. If you were one of the very few to be blessed with IV infusions of NTG, then perhaps you would have more control. Even with this remote possibility, you do not want to use nitrates because of the reflex tachycardia they induce.

I said, you have less control over the effects they exert. Widespread vasodilation is not something you want to cause to a potential intracranial bleed. CHF is a significantly different disease process. Perhaps you should re-read the "book". While you are looking, perhaps you could look for the time frame that it takes to cause irreprable damage to the brain.

Drop the blood pressure, decrease the mean arterial pressure, worsen the ischemia, further damage the brain. The vasodilatory effects of NTG do not allow the heart to slow down. They do allow for greater oxygen supply, not demand. Think this one through for a moment. Create a relative hypovolemia, through vasodilation. How is the body going to respond? Through tachycardia, and a further attempt to vasoconstrict.

Why do you insist on name calling? You're not any better than anyone else that has an opinion on how to manage this situation. ERDoc, Rid, chbare, and I have all suggested that this patient should be transported with as little pharmacologic administration as possible based on the best available evidence. Look for some literature that suggests it is appropriate to actively reduce a blood pressure with associated neurologic complaints, even transient ones, with nitrates. Until you do, please keep the insults to yourself.

[Spock]

Good topic although some might be getting a little off track. I would suspect an SAH even though the headache went away until a CT scan either confirms or denies an SAH. The red herring is the nose bleed. I have never heard of epistaxis associated with SAH although anything is possible.

I also believe lowering the BP out of hospital is rarely indicated. NTG is the worst choice because you have to give it frequently and the rebound effect can be worse. I administer anesthesia frequently in our neurointerventional radiology suite and I routinely run a neosynephrine gtt to keep the BP high. Sometimes in the 200 SBP range. IF we need to lower the BP we use beta blockers until the cardene is ready. Cardene is a great drug.

I believe the original question concerned transport status. Lights and siren saves very little time and since you were only 10 minutes from the hospital I see no reason to "red ball it." L&S might only make the BP worse especially if you have a wild driver. Certainly the hospital needs to know they have a hypertensive patient coming in as soon as possible. Did you get any follow up?

Live long and prosper.

Spock

[Spock]

AZCEP--My post came one minute after yours so I did not read it until mine was posted. I couldn't agree with you more!

Live long and propser.

Spock