ACEP Says "Don't Treat Asymptomatic HTN"

[docB]

This is the clinical policy from ACEP about not treating patients with asymptomatic hypertension in the ED. Feel free to whip it out next time a nurse wants clonidine before the patient can be discharged.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Asymptomatic Hypertension in the Emergency Department

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[docB]

There were some interesting editorials in last month’s Annals about the asymptomatic hypertension controversy.

The pro starting therapy in the ED side argues that each ED visit affords an opportunity to intervene on this and other important public health issues and mentions not only hypertension but influenza, HIV, domestic violence, alcoholism, smoking and general injury prevention.

The anti starting therapy in the ED side argues that the problem is a lack of primary care and that trying to move more primary care into the ED will diminish the effectiveness of both primary and emergency medicine.

Each side addresses the issue of “Can you effectively diagnose hypertension in an ED visit?” as you’d expect. The pro starting side says you can and the anti starting side says you can’t. They both site the previously cited ACEP clinical policy and the JNC recommendations.

Pro starting treatment editorial
Anti starting treatment editorial

I come down on the side of not starting treatment in the ED for the reasons mentioned in this editorial and the ACEP clinical policy. I think that’s the majority consensus in the field as well. But rest assured, this will continue to be a controversial subject.

 

[edgesofsanity]

I come down on the side of not starting treatment in the ED for the reasons mentioned in this editorial and the ACEP clinical policy. I think that’s the majority consensus in the field as well. But rest assured, this will continue to be a controversial subject.

Out of curiosity, what type of practice do you work in? I am currently a resident working at a county hospital that is notorious for having long wait times getting into a primary care provider - 3 months or more depending on the clinic. A good number of these patients come into the ER with SBP>160, and DBP>100. The curent teaching to the residents is to start these patients on HCTZ while they navigate their way through the primary care queue, given the relatively minimal side effects and following the JNC 7 guidelines. Do you run into these types of problems in your setting, or do you have access to prompt follow up where you work?

 

[docB]

Out of curiosity, what type of practice do you work in? I am currently a resident working at a county hospital that is notorious for having long wait times getting into a primary care provider - 3 months or more depending on the clinic. A good number of these patients come into the ER with SBP>160, and DBP>100. The curent teaching to the residents is to start these patients on HCTZ while they navigate their way through the primary care queue, given the relatively minimal side effects and following the JNC 7 guidelines. Do you run into these types of problems in your setting, or do you have access to prompt follow up where you work?

I work primarily in a downtown setting with no access to primary care too. And admittedly I have started patients on HCTZ or other stuff. The problem is that trying to move primary care into the ED is a real slippery slope. We already screen for domestic violence, fall risk, smoking cessation, pneumovax and other primary care/public health issues. There are those who advocate doing even more primary care such as HIV screening, cholesterol checks, obesity interventions and so on. So I think trying to move primary care into the ED because the primary care system is flawed is dangerous.

From the medical end of things it's important to note that even if you do embrace this aspect of primary care the ACEP policy says that it may not be possible to accurately diagnose HTN in an ED visit and dropping the BP in asymptomatic HTN or in someone with only transient HTN could be dangerous.

 

[docB]

I've been trying to incorporate this into my practice for a year now and it's not going well. I continue to get tons of push back from patients (I came in here to get my BP down. If you don't give me something now I'm going to give you a bad customer satisfaction rating!) nurses (It's against my license to discharge a patient with a BP of 190/90) and primaries (What? You can't discharge that! They'll have a stroke in my office!)

Most of my colleagues still do it like the old days of the "hypertensive urgency" with a big work up (CBC, BMP, CK, Trop, UA, EKG, CXR, CT Head) and then Clonidine po and discharge. That's clearly not where the EBM is now.

How is everyone else dealing with this?

 

[DrMom]

I'll write an Rx for HCTZ if there is definite HTN (not 140/85) with f/u with PCP or referral for a PCP. If they have SBP >180-ish I'll give something in the ED: clonidine, metoprolol. or the like. If they're truly asymptomatic and I have no reason to look for renal failure or cardiac issues then I don't do workup. Seems like most of the ones I see have some sort of symptom or other concern enough for me to do a BMP at a minimum. I don't hold them in the ED just to prove their BP goes down after I've given something. I don't have too much resistance from my nurses.

 

[MountainEM]

Just finished a month in the ED at UNM. They follow the acep policy I believe. They never seem to Rx new anti-hypertensives in the ED. If someone comes in with cc of HTN, they bring it down by 20% or so and assess if they need a workup from what I observed. THey do not start people on meds that are hanging out with BPs of 1402, 150s, 160s. etc

I think 190 is pushing it in terms of sending them out right then...

I don't know how anyone would assess whether someone needs meds in the ED while they are sick or anxious or whatever. I think you need to trend it and you need primary care to do that.

I am all for EM not having to address asx HTN .

 

[GeneralVeers]

It's our company policy to not treat asymptomatic hypertension, and in fact our company-owned insurance policy will not necessarily cover us if we do and the patient has a bad outcome (i.e. stroke).

I think it just makes sense. Most of the patients with hypertension have not developed it overnight. Even in the case of renal failure, it's probably been a slow progression. There is simply no compelling reason to start it, as likely there will not be complications of hypertension for months to years in most of these patients, and the risk of treatment like stroke would not be defensible in a court case.

We need to stop being the end-all and be-all of medicine. We should know when it's appropriate to intervene in primary-care issues, and when to do nothing and let the patient follow-up.

 

[tonem]

I tend not to do it because my understanding has always been that you can't diagnose hypertension based on one blood pressure. One dose of anti-hypertensive in the ED might make the nurse (or physician) feel better but it has no long term benefit at all (might even be harmful). From a practical standpoint, is it going to make much of a difference if the patient waits until they see either their PCP or the PCP to whom they have been referred? Even if they have to wait 3 or 4 months. If they don't follow up, is the one to three month supply of HCTZ they receive from me in the ED going to make any difference in their long-term prognosis?

 

[southerndoc]

I don't treat in the ED itself (clonidine, labetalol, etc.) unless it's crazy out of control and they are symptomatic.

For asymptomatic hypertension, if it's <160/100 then I don't treat. Anything more gets a BP med started with follow-up for the primary care provider. We generally have quick follow-up, but I start it anyhow. Patients are often happier, and that leads to better Press-Ganey scores. Plus, I think it's the right thing to do.

 

[deleted109597]

I don't. If it's truly asymptomatic, there really isn't anything for me to do. If they've got followup, the only thing I can do by starting a med is to have their PMD change it in a week after they've bought a month's supply. And yes, it has happened. "Why did you start HCTZ, this patient has syndrome X, an ACE would have worked better, etc."
Plus, if I start a med, I need to check and make sure their Cr is appropriate. HCTZ doesn't work if your Cr is too high.
I don't like to check things if I don't have to.
I simply talk to the patient about why I'm not starting a med, and how me treating a one time BP in the ED isn't doing anything.
However, if they've got SOB, CP, or something similar then yeah, they deserve a workup. Headaches are vague, and if your headache is caused by HTN, you likely have something bad going on. Usually the headache causes the HTN instead, and if you take the pain away, the BP gets better.

 

[Venko]

Both in residency (large academic center) and now in practice (county, VA, and tertiary centers), I have practiced in line with the ACEP policy of very selected and directed workup, and no treatment. Very occasionally, I have seen multiple visits for asymptomatic HTN with multiple elevated BPs and will start a medication after coordinating close follow up with primary care. I have a few colleagues who treat all this stuff, and it kinda makes me insane because then some patients return with that expectation. I have been for a year or so offering the policy to the nurses and to the primary physicians who call to send patients to the ED. There is also a nice EBM review of hypertension in the ED that outlines the evidence behind this recommendation as well.

 

[docB]

I don't. If it's truly asymptomatic, there really isn't anything for me to do. If they've got followup, the only thing I can do by starting a med is to have their PMD change it in a week after they've bought a month's supply. And yes, it has happened. "Why did you start HCTZ, this patient has syndrome X, an ACE would have worked better, etc."
Plus, if I start a med, I need to check and make sure their Cr is appropriate. HCTZ doesn't work if your Cr is too high.
I don't like to check things if I don't have to.
I simply talk to the patient about why I'm not starting a med, and how me treating a one time BP in the ED isn't doing anything.
However, if they've got SOB, CP, or something similar then yeah, they deserve a workup. Headaches are vague, and if your headache is caused by HTN, you likely have something bad going on. Usually the headache causes the HTN instead, and if you take the pain away, the BP gets better.

If they've got SOB, CP, etc. then do you admit them? Those are signs of end organ damage and the ACEP position would seem to be that if they are failing that stress test they merit an admission. That's the problem I keep running into is that with this loss of the "Hypertensive Urgency" catagory it seems like all or nothing. I'm no bemoaning the end of HTN urgency I'm just trying to figure out how to live without it.

 

[WilcoWorld]

Patients with CP, SOB, vision changes, or worsening renal function are by definition not asymptomatic, and I approach them very differently.

I see no reason to try and get the BP down in the ED if there is no end organ symptomatology and I see a lot of reasons NOT to.

To be honest, I kind of think of these patients like a hot potato - the longer they stay in the ED, the more BP measurements the nurse records the higher the numbers get, the more chances they have to decide that they actually did seem to have a little blurry vision a few days ago, etc... and the next thing you know the patient is going to the ICU on a nitroprusside drip with an arterial line in place, and that's not good for anyone.

One thing I will do on these patients is take the damn BP myself. It seems that the vast majority of these frightening pressures are much better when the patient and cuff are properly positioned.

 

[chuck deli]

Another thing that drives me nuts is the "I have a headache" and my blood pressure is high. Now, my understand is that headache does NOT equal hypertensive urgency/emergency (with normal neuro exam, no confusion, no blurry vision). In my practice I don't get too worked up over headache + HTN and I tend to offer ibuprofen and close outpatient follow-up, however several of my colleagues will low the BP in the ED for headache, do the "over-the-top" work-up for HTN (ekg, head CT, urine, labs), and discharge with medications.

I suspect part of this practice is that our triage nurses tend to triage HTN + Headache as an ESI 2.

 

[NeuroSync]

Just finished a month in the ED at UNM. They follow the acep policy I believe. They never seem to Rx new anti-hypertensives in the ED. If someone comes in with cc of HTN, they bring it down by 20% or so and assess if they need a workup from what I observed. THey do not start people on meds that are hanging out with BPs of 1402, 150s, 160s. etc

I think 190 is pushing it in terms of sending them out right then...

I don't know how anyone would assess whether someone needs meds in the ED while they are sick or anxious or whatever. I think you need to trend it and you need primary care to do that.

I am all for EM not having to address asx HTN .

You're correct. UNM follows ACEP guidelines and we do not treat asymptomatic HTN. We have a patient population with poor PC access, but we still follow the guidelines. There is some push back from both nurses and patients, but it seems that the vast majority of providers and residents do not treat, and do not send patients out on meds, given that we cannot follow them.

 

[leviathan]

The recommendations for HTN diagnosis + treatment requires multiple visits to the primary care doc with persistent hypertension. I think the only way you can diagnose it on a first visit is if there is a hypertensive emergency or urgency (SBP>210, DBP>120). Of course those are just guidelines but I don't think anyone could fault you for sending a patient home with asymptomatic HTN since that is what most guidelines tell you to do, even as a family physician. You could leave a note with their primary care doc that "visit 1" has been done to expedite the diagnosis.

http://www.pulsus.com/journals/pdf_...nt of risk, Pulsus Group Inc&HCtype=Physician

 

[chimichanga]

...I suspect part of this practice is that our triage nurses tend to triage HTN + Headache as an ESI 2.

pardon me for chiming in, but this is a very salient point...

I teach ESI, and we teach the nurses not to assign an ESI level based on what you may think the doc would do, only treat the symptoms, but we all know what really happens...

This is the major flaw with the ESI system...The triage RN will undoubtedly asssign an ESI level based on many other factors (her years of experience, i.e. what most docs, in her experience, would do in this situation; read: algorithmics)

"back in the day" (15 years ago, almost every HTN with a headache got a workup, thus the ESI 2...that's where likely a lot of nurses are coming from)

it's flawed logic on the nurse's part, but unfortunate reality...
it can be tough to NOT triage based on which doc is on (or one's own personal history/experiences)...some docs have a rep for working most every pt up...now we certainly don't and won't understand all of the whys behind the workup, but we know which docs just can't dispo a pt in a timely manner, due to the shotgun approach to his practice (and certainly other throughput factors, like lazy nurses)

it speaks to doc b's original post...nurses want clonidine before dc w/ a BP of 160/100, because that's how it used to go, always...

hell, we used to poke a nifedipine capsule and squirt it under the tongue for said pt before dc...now we don't...
it's just the pattern we're used to...falls under the 'we don't know what we don't know category'

quietly back to lurking...thanks for the vine!

 

[zeitgeber]

I rarely treat asymptomatic HTN and completely agree with the ACEP policy. I think the biggest issue for my colleagues who do treat are the patient satisfaction/patient expectation issue. I am concerned about this to a certain degree and attempt to mitigate it with a semi-long discussion on HTN, the importance of a primary care doctor in treating HTN, the difficulties in titrating meds and try to dispell the beliefe that it's an emergency.

 

[roja]

I rarely treat asymptomatic HTN and completely agree with the ACEP policy. I think the biggest issue for my colleagues who do treat are the patient satisfaction/patient expectation issue. I am concerned about this to a certain degree and attempt to mitigate it with a semi-long discussion on HTN, the importance of a primary care doctor in treating HTN, the difficulties in titrating meds and try to dispell the beliefe that it's an emergency.

What zeitgeber said.

 

[EMRAGE]

We often run into this problem. I had an attending one time put it to me like this.

A jury of "your peers" is not going to look at this the same way you do if a patient with undiagnosed (extreme) hypertension goes home to have a stoke.

I'm not saying that I treat all undiagnosed hypertensives, but I do have a threshold that, once surpassed, leads me to treatment. It takes month to get into a clinic in these parts so that forces the issue a bit.

RAGE

 

[pinipig523]

I start HCTZ 25mg po qdaily on these patients. Not an ACEI because they need their Cr checked and not on BB or a CCB for fear of an overdose. HCTZ is pretty benign so I don't mind starting patients who are going to be hard up finding a primary for weeks on it.

 

[xaelia]

Treating asymptomatic HTN IV is like the fever that doesn't go down with Tylenol or Motrin. Does anyone admit viral syndrome with a fever that doesn't go down? Of course not. But we still give them another dose of Tylenol/Motrin and wait for it to look like a relatively sane number like 38.5.

At least, the place I'm moonlighting has a regulation about not discharging fevers >38.5.

 

[GeneralVeers]

Treating asymptomatic HTN IV is like the fever that doesn't go down with Tylenol or Motrin. Does anyone admit viral syndrome with a fever that doesn't go down? Of course not. But we still give them another dose of Tylenol/Motrin and wait for it to look like a relatively sane number like 38.5.

At least, the place I'm moonlighting has a regulation about not discharging fevers >38.5.

I've never understood the insanity of waiting for the fever to "go down" before discharging an otherwise healthy-appearing child. If it's clearly viral and the child is well, what does this accomplish? When a nurse asks me if I want to give something for the fever I usually do, but then tell them to discharge afterwards. I get a few blank looks when I tell them I don't care if the child is discharged with a fever or not.

 

[WilcoWorld]

I'll confess that I'm guilty of this. My reasoning is based on the fact that even with a well-appearing child there's always a small chance that the kid will come back with a serious bacterial infection. If I documented a reassuring H&P and the vitals were normal at discharge, then it's "just one of those things". If the kid's only temp on the chart is 40 C, then to a lot of eyes it's going to look like malpractice.

Does that mean that I wont discharge a kid who looks great just because I can't get his temp below 38? No, but I'll give it a little extra thought.

 

[ER-ER-Oh]

I generally don't treat asymptomatic hypertension. What I do though is sit down with the patient and explain the reasoning thoroughly. I tell them that they're not likely going to have a stroke from blood pressure of 170/100 right now. But I tell them that over years and years of that kind of blood pressure they're likely to develop arterial damage/inflammation that can lead to stroke and heart attacks because it create 'gunk' in the arteries that then can clog up and cause a heart attack, or break off and cause a stroke. That usually gets their attention. I find even the most idiotic patient can somehow grasp this. But, of course, we all know there are some that just go beyond our ability to comprehend how stupid a person can be.

I work both at a large academic trauma center and one of our satellite rural ED's. At the big center I refer to one of many walk-in clinics, while our rural ED has it's own hospital based walk-in clinic.

 

[yahoomail]

I've never understood the insanity of waiting for the fever to "go down" before discharging an otherwise healthy-appearing child. If it's clearly viral and the child is well, what does this accomplish? When a nurse asks me if I want to give something for the fever I usually do, but then tell them to discharge afterwards. I get a few blank looks when I tell them I don't care if the child is discharged with a fever or not.

Its all good if the child goes home and recovers. I guess though, once in a blue moon, the healthy looking child with unresolved fever will go home and have a bad outcome (and not necessarily because of the fever per se), and thats what everyone fears. The documentation will be against you, and I have been told that the jury are not the most medically trained people. To them, discharging a patient who is still febrile will look like sub-standard care. And no matter how much medical evidence you have in your favor, there will be plenty of "expert witnesses" who would easily testify against you. So thats why most docs I know would actually wait for the fever to break before discharging the kid home. Purely for medicolegal reasons.

 

[yahoomail]

It's our company policy to not treat asymptomatic hypertension, and in fact our company-owned insurance policy will not necessarily cover us if we do and the patient has a bad outcome (i.e. stroke).

I think it just makes sense. Most of the patients with hypertension have not developed it overnight. Even in the case of renal failure, it's probably been a slow progression. There is simply no compelling reason to start it, as likely there will not be complications of hypertension for months to years in most of these patients, and the risk of treatment like stroke would not be defensible in a court case.

We need to stop being the end-all and be-all of medicine. We should know when it's appropriate to intervene in primary-care issues, and when to do nothing and let the patient follow-up.

Amen to that !!

Every few shifts I see a patient who has been sent from the clinic or some sort of health screening facilities with a high BP, but are perfectly asymptomatic. I am yet to meet an attending in my training who'd not do a work up on these truly asymptomatic patients. Atleast every one does a set of lytes, and some would do a full cardiac workup. And whenver I try to quote the ACEP policy, the standard response is, "they are already here, why not do some simple blood tests and be sure that everything is ok".
I though thats what the PCP's office was meant for.

 

[docB]

Its all good if the child goes home and recovers. I guess though, once in a blue moon, the healthy looking child with unresolved fever will go home and have a bad outcome (and not necessarily because of the fever per se), and thats what everyone fears. The documentation will be against you, and I have been told that the jury are not the most medically trained people. To them, discharging a patient who is still febrile will look like sub-standard care. And no matter how much medical evidence you have in your favor, there will be plenty of "expert witnesses" who would easily testify against you. So thats why most docs I know would actually wait for the fever to break before discharging the kid home. Purely for medicolegal reasons.

The problem with that line of reasoning is that it's hard to know where to stop. What will yo do if the fever is the same after 4 hours and motrin and Tylenol? Will you then admit the kid? Sign it over to the next doc? How low does it have to be? Is any reduction good enough? Below 100.6? Is your threshold for good enough different at 6 hours than at 1?

It gets tricky when things don't go as planned.

 

[xaelia]

Kids are: sick
or not sick

Some of those pediatric SBI prediction rules for infants 3-6 months of age take into account the height of the fever, but after that, I tell parents that fever is a healthy part of the body's natural infection fighting response.

 

[GeneralVeers]

The problem with that line of reasoning is that it's hard to know where to stop. What will yo do if the fever is the same after 4 hours and motrin and Tylenol? Will you then admit the kid? Sign it over to the next doc? How low does it have to be? Is any reduction good enough? Below 100.6? Is your threshold for good enough different at 6 hours than at 1?

It gets tricky when things don't go as planned.

Agree completely. You have to have a plan if you are going to treat something non-life-threatening. If you really are going to hold the (not sick) kid for a fever to go down, then you should be prepared to admit the kid if the fever doesn't break, and to treat the kid over and over when his concerned parents bring him back repeatedly every time the fever spikes.

The problem I've seen with fever centers on the parents. Many parents apparently have no training in how to raise a child and think that when their kid spikes a fever his or her head is going to explode. I educate parents as best I can on why kids get fevers, and they are common and will likely persist for a few days. I educate them on reasons to return to the ER (not continuing fever).

If there is a single case where an EP was sued because the discharged child continued to have a fever and suffered a bad outcome then I would like to see it.

On febrile kids I am discharging I always document their behavior, i.e: playing, smiling, running around the room, playing video games etc.

 

[docB]

I just hung up with an endocrinologist who is sending in a patient for asymptomatic HTN. It's never going to end.

 

[WilcoWorld]

I recently got a patient transferred from Nephrology clinic for elevated BP without symptoms (obviously the patient already had end organ disease, or he wouldn't be in Nephro clinic). Seriously? If you as the Nephrologist (or the Endocrinologist) can't control the BP what the eff do you think I'm going to do?!

Send 'em home on orals & you're a cavalier ER doc, admit 'em for IV meds & you're a lazy admitting sieve... we can't win.

 

[Hamhock]

I just hung up with an endocrinologist who is sending in a patient for asymptomatic HTN. It's never going to end.

It's tough to blame the general public for "just go to the ER" instead of waiting until the PCP appointment the next day, when physicians (and I intentionally didn't say surgeons) won't do the bit of extra work and "just go to the ER".

How much harder is it for that endocrinologist to call the patient's PCP (just like calling you in the ED) and collaboratively produce an improved antihypertensive med plan? If really worried, send the patient to the lab for a quick Cr and some extra nonsensical blood work and then to the PCP.

I just don't get it.

...but it is a good reminder to attempt to understand folks who show up without symptoms and a chief complaint: "I checked my blood pressure and it was high". I am just waiting for the physician to show up like that.

HH

 

[WilcoWorld]

I have no beef with a lay person who comes to the ED for a high BP after his or her PMD and the media have drilled into them that "hypertension kills". I'm bothered by the people who ought to know more about hypertension then I do (Internists, Endocrinologists, Nephrologists, not Surgeons, not Ophthalmologists) sending patients to the ED for management...and then not even warning them about a wait.

 

[docB]

It's tough to blame the general public for "just go to the ER" instead of waiting until the PCP appointment the next day, when physicians (and I intentionally didn't say surgeons) won't do the bit of extra work and "just go to the ER".

How much harder is it for that endocrinologist to call the patient's PCP (just like calling you in the ED) and collaboratively produce an improved antihypertensive med plan? If really worried, send the patient to the lab for a quick Cr and some extra nonsensical blood work and then to the PCP.

I just don't get it.

...but it is a good reminder to attempt to understand folks who show up without symptoms and a chief complaint: "I checked my blood pressure and it was high". I am just waiting for the physician to show up like that.

HH

To his credit the endocrinologist did call the PMD (at the VA) for advice. To their mutual discredit and my dismay they both agreed that the patient should go to the ER.

 

[AmoryBlaine]

Waaay back in early med school I participated in a "health fair" in a poor area of my city where I was doing ambulatory BP checks. I didn't know much except how to take blood pressure.

Basically all the patients were morbidly obese African Americans so the pre-test for HTN was probably 95%. Started taking BPs.

190/100
210/85
185/105
200/110
175/115

None were on meds and none had a dx (access issues). I think back on that when I see a "scary number." They've been walking around like that probably for months to years so I remind myself that the effects of HTN are long term vascular complications, not that their head is going to blow off and blood is going to start spraying all over the room.

 

[Dwindlin]

They've been walking around like that probably for months to years so I remind myself that the effects of HTN are long term vascular complications, not that their head is going to blow off and blood is going to start spraying all over the room.

The REAL effects of short term asymptomatic HTN. . .

[YOUTUBE]HY-03vYYAjA[/YOUTUBE]​

 

[corpsmanUP]

I just hung up with an endocrinologist who is sending in a patient for asymptomatic HTN. It's never going to end.

That is just too funny! Here is what I do. I sit down, calmly talk about HTN and give a couple of minutes of rhetoric about how long term, not short term HTN is what is dangerous. Then I take a manual pressure and it's always better!!

 

[Hamhock]

OK: I think most of us agree that we don't treat asymptomatic HTN (if previous Dx) or send them on HCTZ at the most, if new diagnosis (+/- checking a potassium).

And I suspect most of us don't consider headache evidence of acute end-organ damage. [please, you others: stop telling me a Cr of 3 is end-organ damage and admitting on a labetolol drip - you think that Cr is acute in the asymptomatic, normal exam patient with a diagnosis of HTN for 5 years].

However, I have run into a bit of wall with a few attendings (I am still a lowly resident). What to do with a headache and BP of 235/140?

My plan is to give headache medicine (APAP or something more - I don't think it really matters), and re-assess. [Now I think my plan should be to give APAP and discharge ASAP.]

The problem occurs when the BP is still 230/145 and still "I have a headache"?

What do you folks do then, in this patient who has no confusion/AMS, no neuro deficits, no N/V, no CP, no SOB, etc.? Just a headache and and this BP?

Do you call it asymptomatic HTN and send home? Do you intervene?

I think, when I am the attending (but I have no idea, as it is not my license or pending med mal case, yet), I will call it asymptomatic HTN and headache...but I am wondering what others think.

HH

 

[Apollyon]

The problem occurs when the BP is still 230/145 and still "I have a headache"?

"Symptoms" are subjective. This patient is now (and has been) symptomatic. Do you know how to acutely test for basal ganglia dysfunction? I don't. And the basal ganglia is the most likely location for injury in hypertensive emergency.

Things not looked for are rarely found. I mean, this person isn't going to have new-onset Parkinson's or hemiballismus, so I don't know what else to tell ya.

 

[xaelia]

I fix the headache. Then, they're 235/120 and asymptomatic. I don't typically use Tylenol; I start with droperidol, if that doesn't work, either Reglan/Benadryl or Valium/Motrin depending on whether I think it's more migrainous vs tension.

Blood pressure to me is a physiologic manifestation of an underlying process, whether it's increased sympathetic tone (from the headache), chronic disease (renovascular hypertension), or CHF/CVA/ICH/etc. Once you've gone down the pathway of saying you're not CT/LP for SAH, and your patient doesn't have PRES, I just work on making 'em feel better.

(when my attending lets me)

 

[WilcoWorld]

I'm an attending, and I'll do three things with the patient HH described - 1st a thorough neuro exam & if it's normal --> 2nd treat the headache with whatever seems most indicated (from APAP to a migraine cocktail to narcotics) 3rd I'll recheck the BP myself manually. You'll be surprised how many >200/100 BP's are more like 160's/90's when you check yourself with good technique.

Then I discharge 'em as fast as I can before a nurse can chart any abnormal vitals or new symptoms!

 

[Apollyon]

2nd treat the headache with whatever seems most indicated (from APAP to a migraine cocktail to narcotics)

The only headaches that indicate narcs for treatment are skull fractures and brain tumors. Please don't tell me you fall for the "but Dilaudid/morphine/Demerol is the only thing that works!"

I had a patient 2 years ago that had a history of migraines (and it was a bummer, as she was a scholarship music performance - piano student, and it was getting to the point where she was worried that she might have to give up the piano), who got the "right" treatment for HA, with Benadryl and Compazine and Decadron, and the doc prior had thrown 2mg of Dilaudid in to "help" - and she bounced back with a rebound headache.

 

[Tiger26]

The only headaches that indicate narcs for treatment are skull fractures and brain tumors. Please don't tell me you fall for the "but Dilaudid/morphine/Demerol is the only thing that works!"

I had a patient 2 years ago that had a history of migraines (and it was a bummer, as she was a scholarship music performance - piano student, and it was getting to the point where she was worried that she might have to give up the piano), who got the "right" treatment for HA, with Benadryl and Compazine and Decadron, and the doc prior had thrown 2mg of Dilaudid in to "help" - and she bounced back with a rebound headache.

Had a 'normal seeming' guy with 170/100 and a "month long" HA seen at an OSH--given 10 mg morphine and started on a nitroprusside drip before sent to us.

Needless to say, benadryl, compazine, toradol and d/c'ing the drip helped things significantly

 

[WilcoWorld]

The only headaches that indicate narcs for treatment are skull fractures and brain tumors. Please don't tell me you fall for the "but Dilaudid/morphine/Demerol is the only thing that works!"

I had a patient 2 years ago that had a history of migraines (and it was a bummer, as she was a scholarship music performance - piano student, and it was getting to the point where she was worried that she might have to give up the piano), who got the "right" treatment for HA, with Benadryl and Compazine and Decadron, and the doc prior had thrown 2mg of Dilaudid in to "help" - and she bounced back with a rebound headache.

Oh hush. You have completely missed my point. I very rarely give narcotics for a headache, but nothing is absolute and sometimes I make exceptions. The point is that I treat the headache, not the BP.

 

[Arcan57]

The only headaches that indicate narcs for treatment are skull fractures and brain tumors. Please don't tell me you fall for the "but Dilaudid/morphine/Demerol is the only thing that works!"

I had a patient 2 years ago that had a history of migraines (and it was a bummer, as she was a scholarship music performance - piano student, and it was getting to the point where she was worried that she might have to give up the piano), who got the "right" treatment for HA, with Benadryl and Compazine and Decadron, and the doc prior had thrown 2mg of Dilaudid in to "help" - and she bounced back with a rebound headache.

There was a recent articles in Annals that showed a significant recidivism rate with migraines. I believe they were looking at whether scheduled NSAIDs after discharge improved rebound HA (which it did), but both tx and placebo group had significant rates of recurrence.

 

[Apollyon]

You have completely missed my point.

Completely? 100%? Really? I don't think so.

There was a recent articles in Annals that showed a significant recidivism rate with migraines. I believe they were looking at whether scheduled NSAIDs after discharge improved rebound HA (which it did), but both tx and placebo group had significant rates of recurrence.

I didn't see the article, but I'm not clear as to your reference to recidivism. Is that a separate episode, or incomplete treatment of one discrete episode?

And, to redirect the thread back on topic, having seen hypertensive bleeds, it colors what I do - I don't bend over backwards to not treat it. I mean, you can vent the fire, and eject the smoke, and wet down the exposures, but you have to extinguish the fire. It's not always the fire as a secondary effect of other things going on.

 

[Arcan57]

I didn't see the article, but I'm not clear as to your reference to recidivism. Is that a separate episode, or incomplete treatment of one discrete episode?

And, to redirect the thread back on topic, having seen hypertensive bleeds, it colors what I do - I don't bend over backwards to not treat it. I mean, you can vent the fire, and eject the smoke, and wet down the exposures, but you have to extinguish the fire. It's not always the fire as a secondary effect of other things going on.

Referring to complete pain relief from original HA with return of same character HA after leaving the ED (forget the time frame but I think it was within a couple of days of presentation).

 

[docB]

2 more asymptomatic HTN transfers from clinics yesterday. 1 from a PMD and the other from a work comp clinic.

I asked the PMD what additional med he'd like for his patient (pt was already on 2) and he said "That's your call." Awesome.

The work comp jackass got really indignant with me when I said we wouldn't do much if the patient was asymptomatic. He started demanding to know if we had Nipride in the ED (he didn't like my answer that we do but I haven't seen anyone use in years).