Hypertension for EMS

We run on patients with high blood pressure all day, and night long. When do we really need to step in and treat them? Let’s start off with some basics, people can be hypertensive for many reasons, some we may not know on scene. Before we think about treating someone we need to ask is the patient causing the blood pressure or is the blood pressure causing the patient. This means is the patients’ condition (chest pain for example) causing the elevated blood pressure or is the elevated blood pressure causing the condition (chest pain). The first patient should have the chest pain treated and the second patient should have the high blood pressure treated. Next, we need to ask, does the blood pressure help the patient, right now? In some conditions, an elevated BP is helpful, 🧠 stroke for example. An acute stroke patient with a BP of 174/82 should not be treated with ant-hypertensives. If you drop their pressure, you will decrease cerebral perfusion and make the stroke worse! Is this chronic or acute, should be your next question. If your patient “lives” at 170’s/90’s, taking them to 120/70 is a bad idea, their body is used to that blood pressure and likely got there over the years. Reducing their pressure in minutes is likely harmful. So when to treat? Let’s use a checklist to see if the patient is eligible for treatment, this does not mean they need treatment.

Treatment Checklist

  1. Is the blood pressure harmful right now to the patient? Loss of vision, AMS, creatinine that has tripled etc..
  2. Is the blood pressure protecting the patient, if so stop, wait, and watch the patient.
  3. Is this acute or have they always had hypertension that is poorly managed?
  4. Are they >85? The elderly can tolerate a higher pressure and benefit from some elevation in BP.

If you went through the checklist and determine that the patient may be treated ask yourself, could this be dehydration related? Remember is the patient causing the BP or is the BP causing the patient. If your patient is dehydrated, the blood pressure is protective. The body has less blood/fluid volume to work with and has increased pressure to maintain flow to organs. Hydralazine is a direct vasodilator and does not have much effect on the venous system. This means that in a dehydrated patient who is “clamped down” to preserve blood pressure, giving them an agent that vasodilates would rocket their pressure to the floor. I’ve seen it happen, many times and unfortunately, it can cause a patient to have a syncopal event or a cardiac arrest. This is the patient who needs IVF, fill the tank, and watch the blood pressure go down. Stay tuned for more quick tips from Dr. Jake

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