Transport priority for hypertensive emergency?

[fiznat]

I'll give you guys a quick run-down of the patient:

54 y/o male was cooking food 15 mins prior to EMS arrival when he had a sudden onset of 10-10 headache pain, "pressing" in nature and radiating to the ears. Almost immediately afterwards the patient's nose began to bleed profusely. Headache went away but nose continued to bleed.

The patient currently denies any pain or SOB. Lung sounds/upper airway is clear. AOx4, PEARRL. C. Stroke Scale is zero. No distal edema, no JVD. Skin warm/pink/dry. Pt denies n/v, dizzy, headache, lightheadedness, synope, blurry vision, etc. Pt says this is the first time this has ever happened to him. He says he is compliant with his meds. Significant dark red blood with clots from the nose and mouth.

HX: HTN only

RX: HCTZ, some unknown "blood pressure" med from W. Africa in an unmarked bottle, ASA

ALL: NKDA

Vitals: BP 280/160 HR 120 RR 22

I understand about "treating the patient not the numbers," but this is a pretty high BP. The patient is basically without complaint besides the bleeding. Airway is easily managed with positioning and occasional suction. Bleeding does slow with pressure + cold compress. We were about 10 mins from the closest ED.

I would like to hear what you guys would think about transport priority. The patient is more or less stable, but I worry that a blood pressure that high can have adverse neuro or cardiovascular complications. It is unknown how long he has been this high but the episode sounds to be fairly acute.

I also understand that you are not "seeing the patient," but what do you guys think?

[AZCEP]

I wouldn't call this a "hypertensive emergency" per say, but would consider doing something for the vitals.

Do you have a beta blocker available? That may be the best route to take, if you are going to.

[fiznat]

Yeah probably more of hypertensive "urgency" since there is no end organ dysfunction. Good point. With a pressure that high though I imagine damage isnt far around the corner though...

We dont carry beta blockers and have no protocol for HTN. The patient got IV lopressor almost immedately in the ED.

It might also help to know that I was working BLS for this call. Still waiting to precept

[ERDoc]

You should get this guy to the ER as quickly as possible. He absolutely has evidence of end organ damage. He is c/o a 10/10, sudden onset headache. This is SAH until proven otherwise. He needs his BP lowered and a CT with a possible LP.

[fiznat]

You should get this guy to the ER as quickly as possible. He absolutely has evidence of end organ damage. He is c/o a 10/10, sudden onset headache. This is SAH until proven otherwise. He needs his BP lowered and a CT with a possible LP.

He was complaining of the headache though... he said it went away after the nose started bleeding. Headache only lasted for a few mins and never came back, all prior to our arrival. Is this typical of SAH?

[ERDoc]

It can be. I once had a guy (sorry to bore you guys with another story) who came in with a sudden onset of severe occipital severe headache. Was feeling better by the time he got to the ER. After being in the ER for a short time the headache came back. He ended up with a huge bleed on CT and was in the SICU for a few days.

[chbare]

I agree with ERDoc, this should be treated as a SAH until proven otherwise. He needs rapid transport the hospital. These patients can be up and talking, then suddenly decompensate. You need to be very judicious when considering correcting HTN with these patients. Not only do we have a bleed and HTN, but vasospasm and secondary injury is also a primary concern with the SAH patient.

Take care,

chbare.

[firefighter523]

Any pt who has any complaints wether, it is dizziness, photophobia, headache, diplopia ect.. with a corolation of a diastolic above 110mmHg would get a full als work up as well as nitrates enroute.

[Ridryder 911]

Some of the controversy is the determination and differential of SAH and AIS. I just became an Instructor for Advanced Stroke Life Support. Part of the curriculum is to NOT lower blood pressure in the field setting. I believe the cautionary approach is some of the difficulties in differentiating between such. However; with improved history and neuro assessment, this should improve field determination. I do wonder on the effects of rapidly lowering the BP versus of maintaining MAP and attempting to decrease ICP? Of course with mortality being of 50% and morbidity of 25%, a need of aggressive treatment needs to be discussed, in which I have seen very little. In fact, treatment modalities have actually shifted opposite direction in the past few years.

Not attempting to hijack a thread, I thought I would add the ASLS thoughts on ASIS patients and the thoughts of HTN :

According to Stroke 200334:1056:

Hypertension & AIS

ASA Guidelines Based on ANECDOTE

In the text of article, guideline authors state:

> Little scientific basis or proven benefit to lower BP in ASIS patients

In general. do not lower BP : the 5 exceptions include

> Aortic dissection, acute renal failure

>Acute pulmonary edema, acute myocardial infarction

>Hypertensive encephalopathy (which is very rare)

No data to define BP values that mandate emergency Rx

Yet they further state:

Consensus based on level V (anecdotal evidence) treat if SBP is >220 or DBP is >120Recall that patient outcomes worse if the BP is decreased in first 24 hours of AIS.

In hospital settings after diagnosing on type of cerebral injury is made, then a more appropriate determination of HTN can be made. Of course one wants to reduce the chance and increasing ICP, but making sure as in the case of AIS injuries of not excessive lowering the BP damaging the penumbra. If considering t-PA and have met then sustained BP> 185/110. It is mentioned that meds such as Nicardine and Labetalol may be considered, and I won't go into detail, since this is ED tx and off the topic.

I hate SAH bleeds, and those that massive tend to ruin my day and rain on my parade. Since we have an encapsulated bleeding inside the skull squeezing the brain there is very little we can do. Unfortunately, they will not let me carry my Black and Decker, and although I have seen anecdotal success in osmodiuresis (Mannitol) and diuretic therapy, with maintaining decreased CO[sub:f512c098c8]2[/sub:f512c098c8] work, I am aware of the controversy and dangers that has been presented with that treatment regime. The last therapy I was informed of, was the focus of brain resuscitation measures of maintaining brain perfusion including fluids and potential blood, which is contradictory to what some have been taught.

R/r 911

[firefighter523]

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!