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Learn More...How do emergency medicine clinicians treat high blood pressure (BP)?
Based on their training, emergency medicine clinicians naturally focus on the identification and management of hypertensive emergencies for those patients with elevated BP. These critical conditions require rapid evaluation and treatment; however, such patients are rare overall, accounting for <2% of ED visits where high BP is noted.
When should emergency physicians initiate hypertension treatment?
Our recommendations are consistent with the 2013 American College of Emergency Physicians’ (ACEP) clinical policy which, based on expert opinion and panel consensus, states that in order to gradually lower BP and/or facilitate chronic BP management, “emergency physicians may choose to initiate hypertension treatment for markedly elevated BP” (de...
Why are intravenous medications used to treat high blood pressure?
These patients need effective and rapid acting medications administered intravenously to lower the elevated blood pressure safely, protect target organ function, ameliorate symptoms, reduce complications, and improve clinical outcomes (1-6).
Which medications are used in the emergency department (ED) for hypertensive patients?
Cannon CM, Levy P, Baumann BM, et al. Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial. BMJ Open2013;3. [PMC free article][PubMed] [Google Scholar]
What is the emergency treatment for hypertension?
In a hypertensive emergency, the first goal is to bring down the blood pressure as quickly as possible with intravenous (IV) blood pressure medications to prevent further organ damage. Whatever organ damage has occurred is treated with therapies specific to the organ that is damaged.
Do paramedics take blood pressure?
0:070:49How to Take a Blood Pressure - EMTprep.com - YouTubeYouTubeStart of suggested clipEnd of suggested clipThat's because the pressure within the cuff is greater than the pressure in the arteries. If you doMoreThat's because the pressure within the cuff is greater than the pressure in the arteries. If you do increase the pressure a little more then release the pressure.
Why is blood pressure important EMT?
BP is an essential cardiovascular variable. Its monitoring is mandatory in any EMS patient, and it has a significant impact on patient management. BP is essential for us to determine when a patient is decompensating and proceeding into shock or is in extremis due to congestive heart failure or hypertensive crisis.
What is high blood pressure EMT?
That being said, the most widely accepted definition of hypertension describes it as:9. • A systolic blood pressure greater than or equal to 140 mmHg, or a diastolic blood pressure greater than or equal to 90 mmHg, or taking antihypertensive medication; or. •
Hypertension: update for paramedics
Hypertension is recognized by the World Health Organisation (WHO) as being one of the leading causes of premature death in the developed world (WHO, 2003). It increases the risk of stroke, heart failure and renal failure (Vasan et al, 2001), yet it is often a hidden disease that is not recognized by those who suffer from it.
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What is a hypertensive emergency?
Hypertensive emergencies classically occur in patients with systolic BP (SBP) >220 mm Hg and/or diastolic BP (DBP) >120 mm H g. 8, 11, 12 Nevertheless, lower thresholds can be associated with hypertensive emergencies in the setting of rapid elevations from low-to-normal baseline BP. Furthermore, BP elevations >170/100 mm Hg can cause worsening target-organ injury in select patients. Elevated BP values in isolation, no matter how high they may be, do not by themselves define a hypertensive emergency unless the patient has concomitant acute organ injury for which immediate BP lowering will modify this injury. Thus, terms such as “hypertensive crisis,” which have been historically assigned to all patients with markedly elevated BP have little utility in contemporary practice. New or worsening end-organ injury occurs in the cerebrovascular, cardiovascular, ophthalmologic, hematologic, and renovascular systems. 9, 13 The most common hypertensive emergencies are stroke (ischemic and hemorrhagic) and acute heart failure leading to pulmonary edema. Hypertensive encephalopathy is a rare and poorly understood condition that may reflect direct adverse acute effects of markedly elevated BP on the brain.
What tests are needed for a hypertensive emergency?
Specific tests are indicated for all patients with suspected hypertensive emergency including a basic metabolic profile, complete blood count, urinalysis, electrocardiogram, and chest x-ray. Further workup of patients with markedly elevated BP should be symptom-based and aligned with each associated condition’s differential diagnosis. Figure 1 demonstrates a general approach to patients with markedly elevated BP. In a patient with altered mental status and BP >220/120 mm Hg, the evaluation includes brain imaging by computed tomography to assess for intracerebral hemorrhage or hypertensive encephalopathy. If neither hemorrhage on computed tomography nor alternative reasons for altered mental status are present, magnetic resonance imaging may be warranted. 17 Likewise, biomarkers of cardiac injury (troponin) and stress (natriuretic peptides) should be obtained for patients with concurrent shortness of breath or chest pain, with the addition of computed tomography angiography of the thorax and abdomen when an acute aortic syndrome is suspected.
What is hypertensive encephalopathy?
Among the diagnoses encompassing the broader grouping of hypertensive emergencies, hypertensive encephalopathy represents the purest form of acute vascular injury from markedly elevated BP. In conditions such as intracerebral hemorrhage and aortic dissection, there is a critical need for immediate BP reduction, but their etiologies are not directly related to a loss of vascular autoregulation. In hypertensive encephalopathy, BP exceeds limits of autoregulation and directly injures the vascular endothelium, leading to cerebral vasodilation and retinal injury often accompanied by glomerular injury and thrombotic microangiopathy. 9, 17–19 Blood flow to cerebral, renal, and other vascular beds is tightly autoregulated to maintain constant perfusion, 20 but this autoregulation becomes overwhelmed at extreme elevations in BP. Each individual’s BP threshold for a loss of autoregulation, however, is dependent on adaption of their vascular beds. In the typical normotensive patient, the brain maintains constant cerebral flow over a mean arterial pressure (MAP) range from 50 to 160 mm Hg. 21 In patients with chronically elevated BP, the autoregulatory system shifts to the right to accommodate a persistently greater pressure load, leading to a higher set-point, which can far exceed an SBP of 220 mm Hg or MAP of 160 mm Hg. Because of the adaptation to chronically elevated BP, most thresholds and targets for treatment should be tailored to each patient. Published thresholds apply to large populations and are based upon expert opinion.
What is the importance of BP measurement in the ED?
BP measurements over minutes to hours using appropriate cuff size and patient positioning can provide valuable information regarding BP variability, range, and trajectory, which can supplement clinic and home BP measurements to guide hypertension diagnosis and medication titration. Multiple studies have shown that BP remains elevated after ED discharge for many patients, and even when BP decreases after ED visits, it does not reach normotension. 33–36 Elevated SBP and DBP in the ED are both risk factors for incident cardiovascular disease, and the risk rises in a step-wise, dose-dependent fashion with increasing ED BP. The number needed to screen to prevent a single cardiovascular event was 151, but that decreases to 71 among patients with ED BP ≥140/90 mm Hg in the ED. ED BP is particularly informative when measured more than an hour after ED arrival and when it remains elevated over repeated measures, 37, 38 but even triage BP provides important information despite the potential for measurement error due to cuff size and patient positioning. Among ED patients discharged with home BP monitors, more than 88% of patients with a single ED triage BP ≥160/100 mm Hg had a mean home BP ≥135/85 mm Hg. 39 Another 46% of patients with elevated BP in the ED met criteria for hypertension in follow-up based on home BP monitor, and it is notable that ED physician gestalt was less accurate than mean ED BP for elevated post-ED BP. 40
How long after ED visit can you get hypertension?
Nonetheless, within weeks after an ED visit, there is a pressing need to improve the care of patients with elevated or previously undiagnosed hypertension. For many, it may be their only regular point of engagement with the healthcare system.
Can aortic syndrome be treated with IV?
While specific symptoms such as acute dyspnea associated with hypertensive heart failure or chest pain concerning for an acute aortic syndrome may prompt immediate treatment before a full diagnostic evaluation, symptoms alone do not define hypertensive emergencies, and ongoing IV antihypertensive treatment should depend on additional diagnostic tests that confirm acute organ injury. For the large majority of ED patients, presenting clinical features are too nonspecific to prompt immediate IV antihypertensive therapy without confirmatory testing. Table 1 describes common symptoms that emergency medicine clinicians encounter when considering new or worsening end-organ injury in the setting of markedly elevated BP. 8 For time-sensitive conditions such as acute ischemic stroke, rapid BP lowering may be indicated when BP exceeds 185/110 mm Hg and thrombolytic or endovascular treatment is planned. 16 Most acute ischemic stroke patients, however, are not candidates for thrombolytic or endovascular therapy, and BP lowering should be avoided. The ischemic penumbra lacks autoregulation of cerebral blood flow and is dependent on systemic perfusion pressure such that acute lowering may worsen ischemia.
Does BP affect pain?
Multiple studies have found no evidence for a relationship between ED BP and pain or anxiety. 41–44 Thus, elevated BP in the ED should not be discounted or explained away by false attribution to pain or anxiety. Given that BP variability is a marker of vascular disease, 45, 46 patients with even temporarily elevated BP in the ED may be at increased cardiovascular risk and therefore benefit from future cardiovascular screening. Long delays in achieving BP control increase the risk of a major adverse cardiovascular event and death, 47 and younger patients with less elevated BP stand to gain the most benefit from antihypertensive therapy. 48
