Transport priority for hypertensive emergency?

[JPINFV]

I'm still trying to find that "stuff." Sure, I'm not a medic, I'm a 4th year bio major. This is why I was asking if lowering the heart rate would be a better option for decreasing BP in a possible hemorrage. It was an honest question and nothing more. Saying "Err, nitrates lowers BP, go me" doesn't answer the question. Telling and explaining are two completely different things.

[firefighter523]

Doc,

With all due respect, your rx for any pt is subject to scrutiny, from other physicians. Just like our rx for our pt are by other paramedics. I do not have the education that you have, and do not claim to know it all. We have protocols, and for a good reason, and they are made up by people like yourself, doctors. We do not have beta blockers in our region, (yet). We only have loop diuretics, opiates, and nitrates for HTN. And we are at the mercy of the doctor on the other end of the line, as it should be. Dont think for one second because you are only 1 of 2 doctors on this forum, that your word is gold.

We use nitrates or diuretics for what might be a HTN crisis.

[AZCEP]

This is not a bleed, you are analyzing this too much

This is a patient that had a neurologic event, and is now hypertensive. What did I miss? I'm still curious how you can be so sure about it not being an intracranial bleed.

and the treatment for this gentleman is to lower his BP.

The prehospital treatment for a hypertensive patient following a neurologic insult is not to reduce the blood pressure through the use of nitrates. You have oversimplified the treatment that this patient needs.

160mmHg (diastolic) is TOO high! NO EXCEPTIONS!!!

Only if you are unable to think outside of your protocols

Go back and brush up on you hx taking skills, or education, one of the two!!!

You really need to consider that this patient is not presenting as a black and white case. Perhaps you've not experienced enough to be familiar with the amount of variability that patients will present with. Perhaps you are restricted as to what your medical director will allow you to do. Either way, you have no grounds to question my education or history taking skill.

You ask me why I would do something that would cause a problem?

And the question stands.

The problem happened already, I want to fix it.

This is not apparent through the modality that you are suggesting be tried. Causing another problem because you've not thought the situation out is not acceptable for anyone.

If his Bp is that high, I DOUBT THAT HE WILL BECOME HYPOTENSIVE.

The use of nitrates will not allow you the control you need to ensure that this patient's intracranial pressure doesn't exceed his mean arterial pressure. Hypotension or not, you should not use a vasodilator for this situation in the prehospital environment.

The fluid bolus wouldn't be needed.

Actually, in the management of an intracranial bleed, even one that is hypertensive, fluid challenges are indicated well before nitrates. I will assume that you've not had an opportunity to look it up yet.

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"??

You have yet to "school" anyone on the proper management of this patient. Very good. You have decided not to wait for your previous poorly thought out treatment to wear off. Perhaps you will be able to use this as your defense when you present your case to a jury of your peers. I'd also be interested in knowing where you were taught that this treatment was appropriate.

JPINV is showing a better understanding of the proper management of this patient, and you feel it necessary to belittle him? Why is this?

[Eydawn]

Ah, firefighter523... I've got to tell you something.

We don't listen to the 2 doctors in this forum because they're doctors. We listen to them because when their statements regarding medicine are evaluated critically and reconciled with available knowledge and literature they, to put it bluntly, "know their $hit". Doesn't mean they're perfect, doesn't mean we must bow down and worship... they're members of this profession who come here to work together with us and further our understanding of medicine as a whole, as well as theirs.

Without performing the appropriate in-hopsital tests you have very little basis for ruling out a neurological insult with the diagnoses that you are able to perform pre-hospital. As such, it is far better to exercise caution in this situation rather than acting quickly and possibly detrimentally. Tell me truthfully.. in the 10-15 minutes that you have this guy in your care prehospital, does the possible benefit that you can confer from dropping his pressure (and subsequently maybe having to treat for hypotension) outweigh the benefits of providing supportive care until you can have more exhaustive tests done to ensure that his problem is not neurological in origin?

There are very few "no excuses" cases with things that are this physiologically and pharmacologically tricky. Not putting oxygen on an asthmatic, well, that's a no excuse scenario. In this one, please allow room for considering other treatments. Do not assume that yours is the gold standard and that, since you are a paramedic, you *must* be right. We all fall prey to human error.

I guess what I'm trying to convey is that while your treatment may be valid in this situation it does not mean that other treatments are not also valid. Consider the complexity of the situation and the human body. Don't get offended when you get challenged; it's part of the learning process.

Also keep in mind that a lot of communication is lost in the forum; a brusque reply may appear to be pissed off, when, in fact it is just a pithy reply because the writer is pressed for time for some reason. Remember that all you have to communicate with are your words, and be willing to cut people slack as much as you deserve it yourself, because at no time can we completely convey everything we're trying to communicate through this forum.

Wendy

CO EMT-B

MI EMT-B

[firefighter523]

Well i guess a CT is the only thing proving either of us right. I know this, If I can't rule out that his BP is causing his headache, and nosebleed, then I must call and ask the doctor if I can treat for it. If he tells me yes, then I will do such. This pt is NOT presenting with a SAH, he is infact presenting with a HTN crisis. Go back a reread the hx. I find it highly coincidental that he got a headache at the same time his nose started to bleed. The fact that his headache went away when his nose started to bleed says it all, - CONTENT REMOVED -

I have treated many pts with command ordered nitrates, and many have resolved at least some of there symtoms. -CONTENT REMOVED- ADMIN

[Eydawn]

Alright, since we're going to hold up certifications here, what kind of educational history do you hold, firefighter523? What is your paramedic's license from? An associate's program? A certification program?

Let's hear it. I want to know. I'm not saying you're not smart; I'm just curious.

Wendy

CO EMT-B

MI EMT-B

[Ridryder 911]

Well, I guess firefighter523 can not read. I posted the national guidelines and indications for lowering blood pressures in the field, which did not include ICP or resuscitation. We quit attempting to significantly lower pressures in the field over 10 years ago, as well as brain reuscitation measures are not reducing of hypertension, since we do not know their normal pressure state and the inability to lower it slowly. Rather emphasis have been to promote more brain perfussion.

Even in the ED setting, they are recommending the BP be lowered at a slow rate and then closely monitored.

I highly suggest looking at ASLS and Brain Trauma web sites for obtaining information on current treatment and modalities, as well as the discussion of NOT lowering pressure in the field setting, especially the use of nitrates.

R/r 911

[AZCEP]

Well i guess a CT is the only thing proving either of us right.

Right about what exactly? The CT does not tell us it is okay to reduce a hypertensive blood pressure associated with neurologic symptoms with nitrates. No treatment guideline does either.

I know this, If I can't rule out that his BP is causing his headache, and nosebleed, then I must call and ask the doctor if I can treat for it. If he tells me yes, then I will do such.

You have to take responsibility for the inappropriate treatment that you are administering regardless of who gives you the order.

This pt is NOT presenting with a SAH, he is infact presenting with a HTN crisis.

How can you be so sure? He had a neurologic event, and is now hypertensive. What assessment tool are you using to determine that this is not a bleed? The crisis that the hypertension is causing is neurologic. This alone should make you consider the possibility of an intracranial bleed.

Go back a reread the hx. I find it highly coincidental that he got a headache at the same time his nose started to bleed.

The coincidence should alert you to the possibility that this is more than it appears to be.

The fact that his headache went away when his nose started to bleed says it all, -CONTENT REMOVED-

What is it saying? Your reply seems to indicate that you have a gross inability to listen to any one else's opinion of what may be happening. You need to familiarize yourself with the current recommendations on blood pressure management in the neurologic patient before you make statements like these.

I have treated many pts with command ordered nitrates, and many have resolved at least some of there symtoms.

Very well. Have the neurologic patients that you have treated in this way had good outcomes following this treatment? Have you done follow up to ensure that there have not been increases in the morbidity/mortality associated with the administration of nitrates? Please educate us on how your system allows you to treat neurologic emergencies despite recommendations from many places to the contrary.

-CONTENT REMOVED-

I do not understand why you feel it is necessary to resort to name calling again. Your system has apparently struck upon a treatment modality that is significantly different than anywhere else. If you could please explain how this came about, without resorting to the epithets, I eagerly await your response. This is not a concern of many others here. I have somehow made you think that I do not believe you know what you are doing. For this I will apologize. I merely want you to explain how it is that your system is capable of not following treatment recommendations.

-CONTENT REMOVED-

I will be glad to when he decides to ask a question that I have expertise in. There are a great many providers that are willing to help students learn. If he asks me, I will answer as I see fit.

PARTS OF THE QUOTE REMOVED TO REFLECT THE REMOVAL OF CONTENT IN ORIGINAL POST - ADMIN

[Just Plain Ruff]

Here is what I find funny

The only time Firefighter523 comes out and posts something is to try to prove all of us wrong.

Eydawn- Firefighter523 has never once told any of us who have asked him and there are many, how many years of experience he has yet he demanded at one time to know how much experience I and other had.

The only time he comes out to post is when he has some insulting to do and there is no surprise that he doesn't like me. He's so much as said so. And in a previous post he said that the fun on this forum was no longer there.

He also in a pm to me said he didnt' give a crap(this is the watered down words) about anyone on this group yet he still comes here and posts.

It almost makes me wonder if he comes to post after he's had a bad day.

I fully expect a diatribe and insults to come from Firefighter523 on this post - I've come to expect no less.

[ERDoc]

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!!!

Man, I can't believe I'm getting involved with this one, but if DocZilla can step up I guess I can too. You CANNOT rule out a SAH based on the history. As I mentioned in a previous post I had a pt with a SAH that was pain free when he got to the ER. Withsome with a BP that high, you are building a pressure head in the vessels in the brain (ie Circle of Willis). This guy probably has a berry aneurysm and when the pressure is building it is causing the pain. That pressure keeps building and building causing more and more pain. Eventually the aneurysm busts. This is what causes the sudden and severe headache. Now you have released the pressure off of that vessel, so the headache is going to subside. The nosebleed was also another way for the pressure to be relieved. If the pressure was high enough to bust blood vessels in the nose, why not the brain? Think of it this way. Let's use a pimple as an example. A pimple becomed more and more painful as it gets bigger because there is a buildup of pressure inside the capsule. The most painful part of a pimple is when you apply a great deal of pressure to pop it. Once it is popped and you havae released that presure there is relief of pain.

Lowering the BP in the field is not a bad idea. Using nitro to due so is malpractice. There are two forces acting with a SAH. You have a high blood pressure which is causing a buildup of pressure and you have a pulse rate which is hitting this weakened vessel like a hammer. Obviously, if you lower the pressure that is a good thing, but you also need to decrease the heart rate so that you decrease the hammering effect on the weak area. Nitro will bring your blood pressure down, but you will get a reflex tachycardia that will hammer away at the vessel so you have essentially done nothing to help your pt. You have gotten rid of one problem by causing another. Beta blockers are probably the best choice in the field because they lower heart rate and BP. That being said, if you use them in conjunction with nitro you will be able to treat the pt better.

Another issue is how far do you drop the BP. We generally do not drop it any more than 20% in the acute setting. The brain works via autoregulation to maintain an adequate cerebral blood flow over a wide range of cerebral perfusion pressures. Your cerebral perfusion pressure is your MABP-ICP. Your ICP will stay constant. So dropping your MABP will decrease your cerberal perfusion pressure. The brain is only able to autoregulate to a certain degree, after which the lower your CPP goes, the lower your cerebral blood flow goes. This means that if you drop the pressure significantly by giving uncontrolled nitrates (ie SL ntg) you will overpower the brains ability to autoregulate and you will drop their cerebral blood flow in a linear fashion. Check out this website for a graph that explains what I am talking about. Autoregulation occurs at the plateau.

http://www.medana.unibas.ch/eng/tcd/tcd2.htm

In the hospital there is a reason we use Nipride (which is a nitrate) and esmolol. Both are quick on and quick off and you have very good control over them.