Treating Hypertension

[tchristifulli]

So a recent discussion has me thinking a bit. 48 yr male patient who states he has a tearing sensation in his chest. Bp 200/111, Hr 100,RR 22. EKG is normal. You suspect an aortic dissection. You are on an ALS rig. Would you treat the hypertension?

 

[DrankTheKoolaid]

I would treat the chest pain which in turn would lower the BP. If i was thinking cardiac NTG , ms. If I was thinking dissection as much morphine as bp would allow

 

[Handsome Robb]

What do you plan on using to treat it?

I wouldn't give this patient NTG. If they are dissecting the potential rebound HTN could be the straw that broke the camel's back.

How far from the ER are we? Is that hospital capable of providing definitive care or is there a facility that's a bit further but is capable that you're allowed to transport to?

If we're far enough out that I feel forced to address it I want labetelol. The alpha antagonistic effects plus the negative chronotropic effects are what I want.

 

[TransportJockey]

With my current protocols i would give morphine to 20mg and see how they do.

 

[tchristifulli]

Would you be concerned that vasodilation would make the dissection worse?

 

[TransportJockey]

Would you be concerned that vasodilation would make the dissection worse?

Slightly yes, but in small doses over time not so much. Or I could just go with up to 3mcg/kg fent. I have a long enough transport time I can titrate both to pressure and pain levels.

 

[tchristifulli]

Your purpose in fentanyl is just to take away the pain?

 

[STXmedic]

Your purpose in fentanyl is just to take away the pain?

The anxiolytic effect of fentanyl would be beneficial, as well. I'd personally use morphine as my initial choice, though.

 

[VFlutter]

Unless you have beta blockers, preferably labetalol, I would not primarily treat the hypertension. I would avoid NTG. Then max out your pain management and sedation as allowed.

 

[TransportJockey]

Your purpose in fentanyl is just to take away the pain?

Anxiolytic, pain control, and reduced MVO2, primarily. I don't carry any antihypertensives, so I can do my best to help the body control itself all on it's own.

The anxiolytic effect of fentanyl would be beneficial, as well. I'd personally use morphine as my initial choice, though.

With a pressure like that, MS would most likely be my first choice as well.

 

[Rialaigh]

mmm I am going to treat the pain but have no plans for BP reduction other then what pain control alleviates. A bp of 200/111 in the presence of suspected aortic dissection is bad but with transport times for me of always less than an hour I really can't think of any circumstances in which I am going to try and control BP at all in the field.

There are some great articles and podcasts out there on the difference between hypertensive emergency and hypertensive urgency. The progressive ER physicians are sending people home with BP's of 260/140 because there are no signs of end organ failure and frankly that BP is not an acute event, it's a chronic problem that is solved by careful dosing of multiple oral anti-hypertensives.

I can almost assure you that there is no difference in mortality and morbidity for any condition which is treated or not treated pre-hospital for hypertension. (all other factors equal). I just see no evidence (thus far) that shows any indication for prehospital treatment of hypertension. Now if you want to talk extended IFT transports than that is a different ball game.

 

[Handsome Robb]

Would you be concerned that vasodilation would make the dissection worse?

Yes but at 200/111 I'm worried about rupturing that aorta and watching him die on my cot with nothing I can do to stop it.

 

[Carlos Danger]

The whole goal of therapy in a dissecting aneurysm is reduction of aortic wall tension, which requires reduction of both HR and MAP.

Analgesia alone is likely not enough, though fentanyl in large enough doses is a good sympatholytic.

Labetolol is an OK choice. Esmolol is better, IMO. Nitrates are fine but are usually given with a beta blocker in order to reduce chronotropy.

There are different protocols out there, but a common goal is an SBP of 120 or less and a HR 60-70.

I once transported a patient with a dissection who had been intubated so that he could go on a propofol drip because of intractable pain and hypertension. I don't remember what all they tried before the propofol, but he was on a large dose of it as well as nitrates and beta blockers.

 

[Handsome Robb]

The whole goal of therapy in a dissecting aneurysm is reduction of aortic wall tension, which requires reduction of both HR and MAP.

Analgesia alone is likely not enough, though fentanyl in large enough doses is a good sympatholytic.

Labetolol is an OK choice. Esmolol is better, IMO. Nitrates are fine but are usually given with a beta blocker in order to reduce chronotropy.

There are different protocols out there, but a common goal is an SBP of 120 or less and a HR 60-70.

I once transported a patient with a dissection who had been intubated so that he could go on a propofol drip because of intractable pain and hypertension. I don't remember what all they tried before the propofol, but he was on a large dose of it as well as nitrates and beta blockers.

Now I've gotta go read a bunch about esmolol and try and figure out why you prefer it....thanks

Didn't really think of nitrates in combination with beta blockers, definitely makes sense. Would you be alright with sublingual? I'd think the rapid dilation and constriction could make things worse...NTG drip makes sense.

 

[Carlos Danger]

Now I've gotta go read a bunch about esmolol and try and figure out why you prefer it....thanks

Didn't really think of nitrates in combination with beta blockers, definitely makes sense. Would you be alright with sublingual? I'd think the rapid dilation and constriction could make things worse...NTG drip makes sense.

It's a really good drug to know. You'll probably see it a fair amount in CCT and flight.

Esmolol vs. labetolol is just my personal preference....I just think esmolol is easier to use and more predictable (I also like metoprolol better than labetolol for the same reasons; again, just based on my experience). Both are pretty good at dropping BP & HR. I'm not aware of any evidence that esmolol is a better drug for this purpose. At the end of the day, I think any drug or combination of drugs that brings both arterial pressure and HR down to the low-normal range is a good thing in these patients, and there are numerous drugs that can do that.

As far as ntg drip vs. SL, obviously a drip gives you more consistent and titratable effects, but I would think in a patient with high BP who you really suspected of having a dissection, SL ntg would be better than not treating at all. Of course things like severity and transport times and other co-morbidities come into play, as well.

 

[medicsb]

FYI, the aorta does not dilate and constrict beyond the recoil produced with each stroke volume. The diameter of the aorta will not get bigger with vasodilation.

Nitrates are not preferred, but they can be used. And it is the hypertension that is most dangerous with aortic dissection, so reducing it directly will be better than trying through indirect means (e.g. pain control).

 

[Handsome Robb]

FYI, the aorta does not dilate and constrict beyond the recoil produced with each stroke volume. The diameter of the aorta will not get bigger with vasodilation.

Nitrates are not preferred, but they can be used. And it is the hypertension that is most dangerous with aortic dissection, so reducing it directly will be better than trying through indirect means (e.g. pain control).

Learn something new every day. Thank you!!

I will ask would the potential rapid changes in afterload both reducing and increasing cause any concern? I guess the dissection has a similar pressure change going between systole and diastole though...

 

[mycrofft]

Another concern: this person is going straight to surgery, maybe a quick ultrasound at the receiving door. What do your surgeon and anesthesiologist want? Be a bummer to get the pt there with vital signs, but the op fails because of pharmacy or spoiled venous access.

Any protocols ought to include the receiving facilities' input, and once adopted all receiving facilities need to know what they will receive..then prehospital techs need to follow them.

I didn't think a vasodilator would directly change a central major vessel, they are actually vaso-relaxers, right? Major vessels don't experience the neuro-muscular vasoconstriction peripheral vessels do. Plus in us old calcified specimens, they're pretty non-flexible to begin with.

 

[tchristifulli]

FYI, the aorta does not dilate and constrict beyond the recoil produced with each stroke volume. The diameter of the aorta will not get bigger with vasodilation.

Nitrates are not preferred, but they can be used. And it is the hypertension that is most dangerous with aortic dissection, so reducing it directly will be better than trying through indirect means (e.g. pain control).

Where can I find information on the Aorta not responding to vasodilators?

 

[STXmedic]

Physiology textbooks