Another Systolic BP Drop

[mrswicknick]

Had this pt yesterday, most of the symptoms were explained but I wanted to get some other thoughts.

81 yof, LRQ pain, non-radiating, no palpable mass/pulsations, pedal pulses present throughout transport. Pain was 10/10 in relation to childbirth, noticeable grimmace, present for 1 hour but had been noticeable for the past day. Vomited on scene, but N/V was absent during transport. Pt was pale and diaphoretic, pertinent past Hx of Colitis, HTN, diabetes with a BGL of 160 and morbidly obese. Pt was GCS 15, no hemipareses or stroke symptoms, general exam was unremarkable.

Here's my question. The abd pain and N/V was pretty well explained with the colitis, she explained that she was instructed by her MD not to eat peanuts as it exacerbated the condition, and of course she had eaten some that day. However, BP for the first 45 min of transport was 220/P consistently, and was figured to be a factor of not having taken her HTN meds, where it is usually 130/90 with medication. Our original thought was Silent - MI and was eval'd by a Medic, found NSR and cleared for BLS. However, about 50 min into transport (Closest ER requires ferry transport) her systolic drops to appx 140/P, however no compensation from pulse or any other remarkable change to suggest any hemmorage, pedals present consistantly. Right around that time, pain subsided to 1/10 and pt seemed to be totally fine. Contacted Med Control and didn't delay transport as it was only 5 min from the dock for any further evaluation.

What would you have done? Can someone with a higher level of understanding explain what could have caused this drop? Could pain have anything to do with the change?

Thanks

 

[mrswicknick]

Also BP did not drop after that point for the next 30 min.

 

[DrankTheKoolaid]

Sigh, why would a so called medic BLS this patient for a 50 minute transport. If one of our employees did that they would not be employed long. For you as a BLS provider the only thing you could have done differently is to push for that medic to do his/her job and taken care of the patient. Negative EKG or not this was a potentially unstable patient.

LOL with hypertension and 10/10 belly pain should have received an IV and analgesia and preperation for a crashing patient. Ive had a similiar that went hypotensive and shocky that required 3+ L of fluid in the ED to maintain 80 systolic after she crashed from the 160's

As to why the sudden decrease in bp and pain not quite sure. Could have been the inflammed portion of the ascending bowel cleared the fecal matter causing the irritation

 

[mrswicknick]

Sigh, why would a so called medic BLS this patient for a 50 minute transport. If one of our employees did that they would not be employed long. For you as a BLS provider the only thing you could have done differently is to push for that medic to do his/her job and taken care of the patient. Negative EKG or not this was a potentially unstable patient.

To be fair, I should add that the exam wasn't just an EKG from the medic, but a full on exam. Also there may be some things that the medic found so show the pt would be stable for the duration of transport. With that said, I understand your point.

 

[Remeber343]

I would have to agree with Corky though. Some places teach not to give px management with abd px as to cover up symptoms and presentation to the ER doc. I'm not saying that's why the medic didn't ride in, i'm sure they had their reasons (I hope). I think it's perfectly fine to make them a little more comfortable.

And as to the pressure changes, it's a lot of excitement having people in blue show up, also, pain can affect pressures. So did her pain level drop and her pressure followed? It happens plenty of times, people call 911, we notice they have high BP, and throughout the transport it will drop. I think it has to do with anxiety and getting the patient comfortable and more relaxed. If i had 10/10 px that felt like child birth, thank god i'm a guy and thats not gonna happen, i bet my BP would be high, along with not taking RX. I do have to say, that is a significant drop in pressure, I'm assuming you guys are using manual and not NIBP? NIBPs can be goofy and come up with some awful readings, personally I stay away from those auto cuffs as much as possible.

 

[mrswicknick]

Well put, and Im glad to see that my assumption was most likely in the right direction with the drop being a part of anxiety/pain. All bp's were manual, I cant stand NIBP, I never use them unless I can barely palpate (read: old) and its too loud to auscultate enroute. Thanks for the input.

 

[DrankTheKoolaid]

The medics exam should have gone no further then skin signs to determine this was ALS

 

[mrswicknick]

The medics exam should have gone no further then skin signs to determine this was ALS

I actually disagree with that, as the diaphoresis and skin color are typical of chronic colitis, and in this case don't constitute ALS, though that was one of the main reasons for the ALS eval.

 

[DrankTheKoolaid]

Actually it is not just typical of colitis, it is typical of a sympathetic response. You note this patient is "morbidly obese". Is this "medic" so skilled he is able to rule out other causes such as a bowel erosion secondary to the colitis and ensuing peritonitis? Do you think a typical ED doc trusts his hands that much, highly doubtful. That is why i would almost be 100% sure this pt received a belly CT, even with her history.

 

[Medic Tim]

Wow. Pt should have gone ALS. The pain management aside.

 

[jedi88]

In my area the medics are supposed to treat any patient with a systolic BP over 180 and ride with us to the hospital, so that alone would have made it an ALS call.

 

[Aidey]

Well put, and Im glad to see that my assumption was most likely in the right direction with the drop being a part of anxiety/pain. All bp's were manual, I cant stand NIBP, I never use them unless I can barely palpate (read: old) and its too loud to auscultate enroute. Thanks for the input.

I'm gonna be blunt, you need to either start liking NIBP or learn how to auscultate. Palping every single BP ever is not acceptable.

In my area the medics are supposed to treat any patient with a systolic BP over 180 and ride with us to the hospital, so that alone would have made it an ALS call.

What exactly are they supposed to do for a BP over 180?

 

[Remeber343]

Treat it with what...? If they are pos bleeding out giving anything could cause issues. Up here we can't give any meds unless it's symptomatic hypertension.

 

[Remeber343]

And I will trust a palpated blood pressure over NIBP any day. Given that an auscultates one is UTO.

 

[Akulahawk]

If my patient is in severe pain, and is experiencing a really high BP, I would consider treating the pain because it could very likely be because of the high BP. As such, careful use of pain meds would have the ability to make the patient comfortable and not mask all of the symptoms of pain and thus make the subsequent exam much more tolerable and accurate. Another thing to consider is that depending upon your local EMS system, you may have medication on board an ALS truck that may also be used for reduction of blood pressure.

Given this patient's history of colitis, and the fact that it was RLQ pain, would lead me to consider two possible causes of her pain: acute appendicitis and colitis. There is not much that I can do in the field for either one, except to attempt to make the patient comfortable and transport the patient to definitive care.

In my opinion, just the necessity of pain control would be enough to warrant an ALS transport. Another thing to consider, is that if this patient had appendicitis and the appendix burst, this particular patient would be running down a really bad pathway, and having no treatment modalities or drugs to assist in resuscitation of such a patient is not a place I would like to be as a provider. That is one of the reasons I went from BLS to ALS…

 

[DrankTheKoolaid]

re

If im reading this correctly not only did this medic turf an obvious ALS patient on a lower provider, he also esentially doomed the patient once they got onto the ferry with no hope of an ALS intercept except at the original dock or the destination dock.

Thankfully it didnt go south on you while on the ship/ferry. I personally would be bringing this one up for review as this is about a crappy a care as you can get. IMHO, but then again I got into this to treat patients..............

And im curious what medications this patient was taking for hypertension as they are not noted. You noted no change in VS as in attempting to compensate for the lowered BP. You do realized 2 types of the mainstream anti-hypertensives will control the rate and remove a patients ability to compensate for actue hypotension, right?.

 

[Melclin]

You could speculate about the causes until the cows came home but this seems like a pretty simple case to me. The working dx you went with (no htn meds + pain) seems reasonable, but ultimately...

"What would you do?"

The pt has pain. Give them pain relief and watch their BP return to normal.

Why on earth didn't she get any?

 

[Handsome Robb]

If im reading this correctly not only did this medic turf an obvious ALS patient on a lower provider, he also esentially doomed the patient once they got onto the ferry with no hope of an ALS intercept except at the original dock or the destination dock.

There's always the possibility of an air intercept if it gets to that point, but depending on the weather that may be impossible.

You could speculate about the causes until the cows came home but this seems like a pretty simple case to me. The working dx you went with (no htn meds + pain) seems reasonable, but ultimately...

"What would you do?"

The pt has pain. Give them pain relief and watch their BP return to normal.

Why on earth didn't she get any?

Sounds like lazy medic syndrome to me. Sounds like someone didn't want to deal with the long transport time. Is it right? Absolutely not but that's what I think.

I'm a big proponent on pain management, it's one of the immediate differences we can make. If you do a good abdominal exam there's no reason that you can't treat someone with abdominal pain.

Even without a good exam, although it's bad form, there's still little to no reason not to treat their pain with the availability of imaging services among other things in the hospital.

 

[mrswicknick]

I'm gonna be blunt, you need to either start liking NIBP or learn how to auscultate. Palping every single BP ever is not acceptable.

I always auscultate on scene, but this pt was large enough that auscultation during transport was too muffled and impossible to hear, in which case I trust palpation more than I do NIBP.

 

[mrswicknick]

If my patient is in severe pain, and is experiencing a really high BP, I would consider treating the pain because it could very likely be because of the high BP. As such, careful use of pain meds would have the ability to make the patient comfortable and not mask all of the symptoms of pain and thus make the subsequent exam much more tolerable and accurate. Another thing to consider is that depending upon your local EMS system, you may have medication on board an ALS truck that may also be used for reduction of blood pressure.

Given this patient's history of colitis, and the fact that it was RLQ pain, would lead me to consider two possible causes of her pain: acute appendicitis and colitis. There is not much that I can do in the field for either one, except to attempt to make the patient comfortable and transport the patient to definitive care.

In my opinion, just the necessity of pain control would be enough to warrant an ALS transport. Another thing to consider, is that if this patient had appendicitis and the appendix burst, this particular patient would be running down a really bad pathway, and having no treatment modalities or drugs to assist in resuscitation of such a patient is not a place I would like to be as a provider. That is one of the reasons I went from BLS to ALS…

Appendicitis was considered, but negated with an appendectomy in her prior Hx, sorry for not posting that part.