Transport priority for hypertensive emergency?

[firefighter523]

AZCEP, the guy was standing, cooking, got a headache, and his nose started to bleed, he also has a hx of HTN. Apparently his gcs is 15. SAH does NOT present like this. If anything does, it would be an epidural bleed, usually from the middle meningeal artery, usually with associated trauma. Subdurals are SLOW to present. You DONT usually get nose bleeds with them, and they DONT just disappear (headaches).

You need to correct the insulting problem, pt's like this USUALLY have hx of HTN, and are not compliant with there meds. 160mmHg is too high to let be. I can understand if this was a hem, BUT IT'S NOT!!! This pt needs his BP lowered, hence that is PROBABLY why his is on BB's!!! If you don't have BB's in the MICU, you need to use what you have in your box!!!

I resort to the name calling because there are people on this site that think that you should NEVER lower BP in the field. Yes , they truely are IDIOTS, and I really don't have a problem with telling them that! If I had a beta blocker, I would ask to give it. That would be the best thing to do.

[firefighter523]

PS AZCEP,

If the pt goes hypotensive, you lay them supine and give them a fluid bolus! You DONT wait 3 to 5 minutes for the nitrates to wear off!!! Don't get stupid because I piss you off, use your head!!

[AZCEP]

And why would you do something that you know will cause a problem, when you can avoid it in the first place? You have not "pissed me off". You are not capable of that. I merely wanted a clarification on why you would choose to treat someone with a modality that is not indicated, and potentially dangerous for the circumstances.

Hypertension associated with a neurologic event is a reason to NOT treat hypertension in the field with the paucity of agents that are commonly available. Because this patient is on a beta blocker is another reason not to treat with nitrates. It is not a reason to initiate a treatment that will cause harm. You also indicated that an epidural bleed can present like this. So why can't a sub arachnoid bleed? Headaches can, and do, dissipate following a vascular event. Not a common presentation, but one that needs to be considered.

Because of the onset, you can reliably rule out a subdural bleed as well? How do you know when it began? Because the patient became symptomatic while cooking dinner is immaterial. This event could well have been evolving over hours to days. The information given is a bit scarce in this regard, and the provider on scene was probably unable to obtain a reliable history from the patient anyway.

Before you make intentionally inflammatory, and obviously wrong statements, please take your own advice and think it through.

[JPINFV]

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. :?

Of course the question is, "Why would you want to increase the volume of the pipe leading to the hole when you could just decrease the volume being pumped (cardiac output)?"

[firefighter523]

AZCEP,

This is not a bleed, you are analyzing this too much, and the treatment for this gentleman is to lower his BP. 160mmHg (diastolic) is TOO high! NO EXCEPTIONS!!! Go back and brush up on you hx taking skills, or education, one of the two!!!

You ask me why I would do something that would cause a problem? The problem happened already, I want to fix it. If his Bp is that high, I DOUBT THAT HE WILL BECOME HYPOTENSIVE. The fluid bolus wouldn't be needed. I was just schooling you on what to do if it does drop, in any case because of too many nitrates. You wouldn't wait 5 minutes till it wore off. Is that clear now "instructor"??

[firefighter523]

JPINFV,

Your statments are irrelevant to this case. Nitrates lower BP, and that is what he needs.

[firefighter523]

JPIN

You must have missed my reply when I said that beta blockers would be a better rx modality for this gentleman. Calm down your eagerness to argue and read the full text of the replys.

[JPINFV]

Lowering the rate would also decrease his BP. Here comes the science (since there are more than two ways to skin a cat... three in this case).

mean arterial pressure=systemic resistance*cardiac out put

Cardiac output=stroke volume*heart rate

Thus

MAP=systemic resistance*stroke volume*heart rate. If you lower any of those, you will lower his blood pressure

[Doczilla]

AZCEP, the guy was standing, cooking, got a headache, and his nose started to bleed, he also has a hx of HTN. Apparently his gcs is 15. SAH does NOT present like this. If anything does, it would be an epidural bleed, usually from the middle meningeal artery, usually with associated trauma. Subdurals are SLOW to present. You DONT usually get nose bleeds with them, and they DONT just disappear (headaches).

There are several inaccuracies in your post and your assumptions about intracranial hemorrhage. It is obvious that you have seen very few, if any, of them.

You need to correct the insulting problem, pt's like this USUALLY have hx of HTN, and are not compliant with there meds. 160mmHg is too high to let be. I can understand if this was a hem, BUT IT'S NOT!!! This pt needs his BP lowered, hence that is PROBABLY why his is on BB's!!! If you don't have BB's in the MICU, you need to use what you have in your box!!!

AZCEP is absolutely correct. a) you don't know the insulting problem, and even if you did, dropping their BP like a stone is a pi$$ poor idea. You should be extremely cautious about lowering the BP in the field, particularly without knowing the details of what's causing the patient's problem. Aggressively lowering this patient's BP, whether from SAH or uncontrolled hypertention, is potentially disastrous.

I resort to the name calling because there are people on this site that think that you should NEVER lower BP in the field. Yes , they truely are IDIOTS, and I really don't have a problem with telling them that! If I had a beta blocker, I would ask to give it. That would be the best thing to do.

There are many medical directors, including myself, who feel that this is a dangerous practice. You might ask to give some lopressor, but if I'm on the other end of that radio, it would not be a very large dose. And the order sure as s#it wouldn't be for nitroglycerine sublingual tablets.

Read more and post less.

'zilla

[firefighter523]

JPIN,

I am sorry you have waisted your time typing all of that "stuff". Wait until you are atleast a medic to argue with the big boys! I am a college student also, do I seem better now??