Prehospital Hypertension

[rhop]

I'll looking for info on any new drugs or treatment on prehospital hypertension. Now that you can't get an order for Procardia for this and recently running a call that the patient needed something the only hope I had was to ask for Procardia. I have been told that Nitropaste was good for this because it was a good way to control the drop in blood pressure. But I would like to do a study on what is the best treatment for this patient, where I can find info to backup my findings and the big question what will it cost. Thanks for any input that you can give.

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[Medic019]

What are your current protocols for this situation ???

[smoke1713]

here in wv we used to give procardia for htn, but there was some controversy dealing with this and inducing cva's, we have no rx for this now, lowering the bp is a side effect of ntg and i don't really think using a se of a drug as a rx, except if cx pn is involved.

[smoke1713]

here in wv we used to give procardia for htn, but there was some controversy dealing with this and inducing cva's, we have no rx for this now, lowering the bp is a side effect of ntg and i don't really think using a se of a drug as a rx, except if cx pn is involved.

[Romania]

They took our nifedipine away (darn, worked great) mostly because of the CVA thing (okay, causing a CVA definatly goes in the BAD column). If you don't have a HTN med or can't get orders your best Tx is ABCs and Oxygen, rapid transport to closest (app.) facility, and treat associated S/S, rate and rythm if appropriate. It is my feeling that more medics need to strive for that 10 minute rule we are taught in BTLS for all unstable medical patients. I have a real hard time giving NTG (of any kind) for a pt who is HTN w/o CP, you aren't effecting the reason they are HTN and you are increasing myocardial oxygen demand. On a side note I have heard of both verapemil and Morphine being used for HTN crisis.

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Alan Romania, CEP
romania@uswest.net
IAFF Local 3449

My Opinions do not reflect the opnions of the IAFF or Local 3449.

[Boothby]

We carry Cardene IV. It is classified as a slow calcium channel blocker. The drug is to be given based on a diastolic BP of >140. This drug is given as a drip and with two different drip rates based on effect. Cardene IV requires VERY close monitoring of patient BP and is not to be used in conjunction with other anti-hypertensive agents.

Now on to NTG. Has anybody ever noticed what they do in the ED with acutly hypertensive patients? They slap about an inch of Nitro paste on their chest and monitor their BP. According to Mosby's paramedic text pp 387-388 NTG is considered an anti-hypertensive agent. We do not have standing orders for NTG in acute HTN, but every time I have called in requesting it I have been ordered to give 0.4mg NTG sublingual every 3-5 min titrated to BP. We all know that NTG is first line for chest pain, but its mechanism as a vasodialator works for short term management of acute HTN. Of course if the patient presents with signs and symptoms of CVA you are NOT going to use it. NTG is also first line for acute pulmonary edema, regardless of chest pain, again for the vasodialatory effects. You can find this in the Essentials of ACLS text pp 1-39 through 1-47. Also in the same text on p8-1 you will find NTG listed as a "Vasodilator/antihypertensive". The bottom line here is that, because of it's mechanism, NTG is an excellent drug for the short term management of acute HTN crisis. I don't give it in this setting without orders, but anytime I request orders for NTG I have been given them and it works.

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Larry Boothby
Firefighter/Paramedic
Truck 3 A-shift
Local 1784
Memphis.

[desoto]

Alan,
I am in complete agreement with Boothby on the NTG issue. Also keep in mind that NTG decreases myocardial oxygen demand, vice increasing it.
Keep up the good work brothers!


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Todd Gritter
Firefighter/Paramedic
Engine/Medic-10
Columbus Division of Fire
Columbus, Ohio

[Romania]

I have to concied that NTG is useful for more than CP, sorry. Especially P/Edema. My statement was invalid, but I still rember being told (repeatedly) that NTG increases myocardial O2 demand (of course I could be wrong, I don't have any medic books at home right now, all at work and lent out http://www.firehouse.com/interactive/boards/frown.gif)I still don't like the idea of giving a NTG pill for HTN crisis. A have seen NTG used in the ER, but the Paste which is both more controlible in doseage and has a slower rate of absorbsion.

Hey, I am always open to new ideas and I plan on researching this more (once I get my hands on my books again). If anyone has some links that have info on this, let me know. Not that I don't trust you guys... but I like to read up on these type of things.

Thanks Brothers

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Alan Romania, CEP
romania@uswest.net
IAFF Local 3449

My Opinions do not reflect the opnions of the IAFF or Local 3449.

[desoto]

I don't know of any links off the top of my head where you might be able to find the NTG information you are seeking Alan. You might try the ACLS site or the Online Journal of Cardiology.
When you do get your hands back on your texts check out the ACLS book (1997-1999) pg. 8-10; " The decline in ventricular volume and systolic wall tension decreases myocardial oxygen requirements and usually reduces myocardial ischemia. "
You were correct in your earlier assertion that by giving nitro you aren't affecting the reason they are hypertensive. Nitro is simply a smooth muscle relaxant. It doesn't affect AV node conduction the way Verapamil does, and it isn't a respiratory depressant like morphine is. Although both of those other two drugs do have some similar smooth muscle affects, the drug of choice by far is NTG.
If you can remember those instructors who repeatedly told you that NTG increases myocardial oxygen demand, look them up and ask them their reasoning, I'd be interested in hearing it.
Stay safe brother!

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Todd Gritter
Firefighter/Paramedic
Engine/Medic-10
Columbus Division of Fire
Columbus, Ohio

[Trauma_Dog]

We are currently managing HTN with nitro spray, which in most cases works well, however, we are using LABATELOL in cases of severe hypertension.

MEDICATION:
Labatelol is a competitive alpha1-receptor blocker as well as a nonselective beta blocker used to lower blood pressure in hypertensive crisis.

MECHANISM of ACTION:
Blocks action on the S.A. node and ventricular muscle causing negative chronotropic,dromotropic and introphic effects. Vasodialation and reduced PVR without reflex Tach.

INDICATIONS:
* SYSTOLIC B/P >240 or a Diastolic B/P >110 with or without S/S.

CONTRA:
* CHF
* HYPOTENISON
* ASTHMA OR COPD
* HEART BLOCK OR BRADYCARDIA

S/E:
* POSTURAL HYPOTENISON
* FEVER
* LIVER TOXICITY
* EXACERBATES CHF
* BRONCHOSPASM
* WHEEZING
* FATIGUE

DOSAGE & ADMINISTRATION:
* ADULT - 10MG IV OVER 1 TO 2 MIN.
* PEDIATRIC - NOT RECOMENDED.

BEFORE WE ARE ABLE TO GIVE LABATELOL A FULL NEURO ASSESSMENT IS MADE AND DIRECT CONTACT WITH THE MEDICAL DIRECTOR ATTAINED. IF HAVE SEEN A INCREASE OF USE OF THE MED IN THE PRE-HOSPITAL SETTING. THANKS FOR YOU TIME.


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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[LuxRes907]

I'm just writing this letter as an EMT-I and not aware of which drugs may be giving in my area for HTN. In one of the posts on the acute hypertension issue I read, "I have a real hard time giving NTG (of any kind)for a pt. who is HTN w/o CP, you aren't affecting the reason they are HTN...." I guess this is true but you may be buying them some time to get to the hospital and find out why there HTN, given there are no know contra to giving NTG. Technically giving NTG to a CP pt. isn't solving the root problem either, its just buying them some time...

just my two cents
Jamie Tlachac, EMT-I

[FIREMEDIC BILL]

I have recently done some research on treatment for hypertension as related to pre-hospital. There is a great deal of complexity in regard to this subject. Fortunately for us, the majority of hypertension we see in the field is related to cardiac emergencies. For example, CHF patients are almost always hypertensive and by treating the CHF we treat the hypertension by giving the pt NTG, lasix, and morphine. Furthermore, patients with angina, whom are also frequently presenting with elevated BP, receive NTG and morpine.

In my eleven years, working full time in public EMS (Atlanta area), I can actually count on one hand how many times I have seen a true "hypertensive emergency." As many other services, we use to carry procardia for such an incident. However, as many other services, we took it off several years ago. This was done because of the potential of a patient with CVA or of a patient with acute intracranial events. By dropping the BP too fast and being too aggressive, this may increase morbidity and mortality.

Procardia worked well the couple of times I administered it to a patient. I would like to read more about labetolol and see a survey on success of it being used in the field. However, due to the low incidents of true hypertension crisis,and for the most part, short transit times to receiving hospitals, it would not be practical to spend the time nor money on labetolol.

Where I work, we currently have a standing order for just about any emergency you can think of, except "hypertensive emergency." We have to call Medical Control and request NTG SL or Lasix 40mg IV.

Hope this info helped. Be safe.

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FIREMEDIC BILLBO RESCUE 8
GWINNETT FIRE/GRAYSON GA.

[Trauma_Dog]

I agree with Bill that you must find the root problem of the HTN and handel it accordingly, our use a labetalol is only used in truly emergent hypertensive crisis.

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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX


[This message has been edited by Trauma_Dog (edited February 27, 2000).]

[SCMedic45]

Procardia was also taken away from us some years back. Labatalol has just been approved for use with on-line MC. I have given it many times in the ED setting and have seen no ill effects--just lower BP's! It seems to have a pretty wide dosage margin and is not nearly as "touch and go" as say Nipride. NTG is not considered an antihypertensive drug around here. Getting to the root of the problem is the most important thing to consider--CHF,ICP, etc.

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Hamilton RN,CEN,EMT-P

[Trauma_Dog]

After my last posting on this subject I did a little research on my own and found out that I did not know as much as I though about the Tx of HTN.

Hidden in the confines on chapter 10 of you acls manual there are actually some quide lines for managing HTN that might raise a few eye brows, yes giving anit-hypertensives to CVA pt's. I would not want to give wrong information so I will just say read it for your own, it really makes good sense.

After you read write me back and let me know what you think.

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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX