Options for headache in a malignant hypertensive with ESRD on HD?

Get the patient in the unit, monitor and lower BP, and I'd have to think that the pain will subside.

Narcotics are generally safe as long as they are dosed carefully. Metabolism is primarily liver, excretion is primarily urine. Monitor their breathing so they don't develop any CO2 retention from opioid intoxication (esp if they have any COPD).

bonovox said:

What would you give a pt. for headache who came in with SBP>240, retinal hemorrhage, Cr>13, and in whom tylenol doesn't help? Intracranial bleed and infarct has been ruled out, and his MAP is being brought down as per protocol. Vicodin?

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Likely the headache is 2* to the hypertension and if you got some jackass that put the pt on a nitro glycerin gtts, you'll never get rid of the horrible headache as long as they're on the nitro drip. If this is the case switch them over to a nicardipine or labetalol gtts, decrease SBP by 20% first hour, and then down under 160 SBP within the next 6-12hrs, restart oral meds, or in this case, get some dialysis, and titrate off the drip.

A big dose of take your meds at home.

Make sure you don't snow them with pain meds cause when the patient doesn't wake up, it is going to be difficult to tell if it is drug related or the ischemic stroke they just had from their blood pressure dropping too quickly.

Esmolol drips can also work well and have a very short half life.

narcs are OK, but go easy on the narcs
agree with other posters the HA is likely from the very high BP and will get better after it's treated.
Other thing besides the HTN and nitro (if he's on nitroglycerin) that could be causing HA in ESRD patients is electrolyte abnormalities. Those HD patients get a lot of weird aches and pains, leg cramps, etc. too, even sometimes when the electrolytes on the BMP look OK. I think they have a lot of weird fluid and electrolyte shifts. It's hard to make ESRD hemodialysis patients "feel good". They are sick puppies.

Medicine fellow.