What is the highest diastolic pressure you have ever heard about?

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vtucci

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Yesterday I was at my family medicine outpatient clinic, when I heard about a 50-something WM who was in the clinic (and was seen by another attending) who had a diastolic pressure of 180. That's right folks- diastolic of 180 not systolic.

I saw the patient briefly in the hallway. The truly amazing thing was that he was walking around with a couple attendings (the first attending had consulted my attending. they were taking him to another BP machine because they believed that the first machine must have been improperly caliberated- the second machine showed the same thing and so did their manual readings). The patient looked a little unhappy but was not grossly diaphoretic or in acute pain or distress. Truth be told, the doctors looked worse than the patient.

Needless to say, he was sent to the ED. I have not heard the outcome yet.

The attendings had never heard of any diastolic pressure that bad before so I ask you all, what is the worst you have ever seen or heard about? What did you do to treat the patient who had it?

Cheers,
 
vtucci said:
Yesterday I was at my family medicine outpatient clinic, when I heard about a 50-something WM who was in the clinic (and was seen by another attending) who had a diastolic pressure of 180. That's right folks- diastolic of 180 not systolic.

I saw the patient briefly in the hallway. The truly amazing thing was that he was walking around with a couple attendings (the first attending had consulted my attending. they were taking him to another BP machine because they believed that the first machine must have been improperly caliberated- the second machine showed the same thing and so did their manual readings). The patient looked a little unhappy but was not grossly diaphoretic or in acute pain or distress. Truth be told, the doctors looked worse than the patient.

Needless to say, he was sent to the ED. I have not heard the outcome yet.

The attendings had never heard of any diastolic pressure that bad before so I ask you all, what is the worst you have ever seen or heard about? What did you do to treat the patient who had it?

Cheers,
Click to expand...

I've seen patients in the range you're speaking of. A few in the 190s and a couple over 200 Diastolic. It depended on their complaints (i.e Hypertensive Urgency vs. Emergency) on how they were treated.
 
Always make sure the systolic is higher than the diastolic pressure - otherwise the blood flows backwards...................:laugh:
 
Can somebody write the epilogue to the story? Curious med students want to know...
 
southerndoc said:
When I was rotating in the MICU, I admitted a patient who had a systolic BP of "greater than 300" and a diastolic of 240. When I inserted the A-line, blood literally shot across the room. Initial systolic pressure by A-line was 320.
Click to expand...

damn - did the blood flow back up into the pressure bag? we normally inflate them to about 300😀
 
FISKUS said:
Always make sure the systolic is higher than the diastolic pressure - otherwise the blood flows backwards...................:laugh:
Click to expand...

Holy s*** that's funny. Does that happen with the arterial smooth muscle just decides it's had enough and starts pushing back?
 
We had a 260/180 in the ED by machine confirmed by manual. History of uncontrolled high blood pressure. Presented because of two days of nosebleeds. He stated he gets them when his systolic gets over 250 so he came for treatment. Takes no meds except during the odd visit to the ED. After receiving some labetalol and getting his pressure down a bit he signed out AMA despite the best efforts of the attending. He wasn't interested in being admitted or even getting a clinic appointment.
 
Seen 300/180 before. In our population our average ED baseline SBP has to be around 200-220.
I'm constantly discharging patients with BP's of 220/120 and a script for HCTZ or metoprolol.
terrifying what is happening to their bodies.:scared:
later
 
Around 300/200 in a prison inmate who used his uncontrolled hypertension to get out of the state prison and into the hospital. A lesson to those still in residency: asymptomatic hypertension with no acute end-organ damage is not an emergency. I can't count the number of patients that get sent to the ER with a chief complaint of "OMG! His systolic blood pressure is 200!" I'm like, "Yeah, and...?"
 
Sessamoid said:
Around 300/200 in a prison inmate who used his uncontrolled hypertension to get out of the state prison and into the hospital. A lesson to those still in residency: asymptomatic hypertension with no acute end-organ damage is not an emergency. I can't count the number of patients that get sent to the ER with a chief complaint of "OMG! His systolic blood pressure is 200!" I'm like, "Yeah, and...?"
Click to expand...
Yeah, I made that mistake a few years ago...220/160 and I freaked. :laugh:
 
Sessamoid said:
Around 300/200 in a prison inmate who used his uncontrolled hypertension to get out of the state prison and into the hospital. A lesson to those still in residency: asymptomatic hypertension with no acute end-organ damage is not an emergency. I can't count the number of patients that get sent to the ER with a chief complaint of "OMG! His systolic blood pressure is 200!" I'm like, "Yeah, and...?"
Click to expand...

Yeah but as far as I understand it it is still an "urgency" right? I mean if someone comes in 200/100 don't you have to lower it from a medicolegal standpoint?

As a side note I took a bunch of blood pressures at a health fair a few weeks ago. It was absolutely amazing. I would say that 60% of the people were obese and the average systolic was in the 170s-180s. Their excuses for their HTN included

"yeah, I just walked over here."
"oh, well I did just have lunch."
"we had a really stressful meeting at work 2 hours ago."
"it's always high when I get it taken."

Riiiiiiiight. If I take a BP on an AA lady with a BMI of 35 who is eating a bag of Doritos while I inflate the cuff, I'm going to be sure to go ahead and chalk her 165/95 up to "lunch."
 
AmoryBlaine said:
Yeah but as far as I understand it it is still an "urgency" right? I mean if someone comes in 200/100 don't you have to lower it from a medicolegal standpoint?
Click to expand...
No. They've had that BP probably for years, and they'd easily survive many more years with that BP. High systolics don't kill giraffes the instant they stand up, and they don't kill humans acutely either. The real danger is lowering it too quickly or hitting them with BP meds that make them dizzy, fall down, and break a hip.

The only hypertensive emergency you're likely to see much of in the practicing world is hemorrhagic stroke. The rest are pretty rare in the grand scheme of things. Even with ICH, you don't want to drop the BP too much. Most of the neurosurgeons I've worked with just want the systolic below 180-200 in a hypertensive ICH. They most definitely do not want it "normalized".
 
36 y/o F with 250/150 today, with headache, neuro intact. With diffuse SAH - "a classic presentation on CT", per the radiologist.

Probably popped a berry aneurysm. Not always benign. I have colleagues that would not have scanned her head.
 
Apollyon said:
36 y/o F with 250/150 today, with headache, neuro intact. With diffuse SAH - "a classic presentation on CT", per the radiologist.

Probably popped a berry aneurysm. Not always benign. I have colleagues that would not have scanned her head.
Click to expand...

Just curious. What was the presentation by history? Bad headache in a patient without a history of "migraines"? I scan all those regardless of BP. With that BP and a bad headache, it's a "no brainer". (Ba-dum-bump)

I've had lots of belly CT's I know a lot of my colleagues (and some of my surgical consultants) have told me they wouldn't have scanned turn out to be early appendicitis. Too bad we don't get awards for good "catches".
 
Sessamoid said:
No. They've had that BP probably for years, and they'd easily survive many more years with that BP. High systolics don't kill giraffes the instant they stand up, and they don't kill humans acutely either. The real danger is lowering it too quickly or hitting them with BP meds that make them dizzy, fall down, and break a hip.

The only hypertensive emergency you're likely to see much of in the practicing world is hemorrhagic stroke. The rest are pretty rare in the grand scheme of things. Even with ICH, you don't want to drop the BP too much. Most of the neurosurgeons I've worked with just want the systolic below 180-200 in a hypertensive ICH. They most definitely do not want it "normalized".
Click to expand...

I guess that's my question. Say you d/c someone home with 210/105 and then God-forbid they stroke out the next day. Seems like the trial lawyers would just be salivating...

I know tons of people "hang out" super-high, but that seems like a dangerous assumption to make when you first see them... Thanks for the perspective, I'm still a rookie.
 
AmoryBlaine said:
I guess that's my question. Say you d/c someone home with 210/105 and then God-forbid they stroke out the next day. Seems like the trial lawyers would just be salivating...

I know tons of people "hang out" super-high, but that seems like a dangerous assumption to make when you first see them... Thanks for the perspective, I'm still a rookie.
Click to expand...

If something bad happens to one your patients, there's a chance you'll get sued. It doesn't matter whether you did anything wrong or not. Whether you win/lose/settle the suit also has nothing to do with whether or not you did anything wrong. The key determinants in the outcome of a malpractice suit (aside from gross negligence) are 1) the respective quality of the lawyers, and 2) the piteousness of the plaintiff. Get sued for a sick/dead kid? Just settle. You can't win those, and even if you do it'll hurt you for a long time.

You can choose to admit all people with systolics greater than 160/180/200/whatever, but there's no good proof for it. If you're that risk-averse, I'd venture that EM is not the right specialty for you. Bringing it down temporarily just to get a lower number on the chart may look good to a lawyer (then again, it may not), but it realistically doesn't accomplish anything in the asymptomatic patient with chronic, essential HTN. I generally equate that kind of behavior with nurses chasing fevers in kids that look just fine. It makes (some of) us feel better, but it doesn't really do anything for the patient except make them wait longer and risk medication side effects. I usually just start them on a low dose of something fairly benign and send them to follow-up with their PMD or the on-call internist.
 
Sessamoid said:
Just curious. What was the presentation by history? Bad headache in a patient without a history of "migraines"? I scan all those regardless of BP. With that BP and a bad headache, it's a "no brainer". (Ba-dum-bump)

I've had lots of belly CT's I know a lot of my colleagues (and some of my surgical consultants) have told me they wouldn't have scanned turn out to be early appendicitis. Too bad we don't get awards for good "catches".
Click to expand...

HTN on two meds ("HCTZ and I can't remember the other"), noncompliant secondary to running out for a little over 2 weeks. Headache after waking up Sunday morning, moderate, not the worst in pt's life. No neck pain - all frontal.
 
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