Aymptomatic HTN...that actually has damage

[wareagle726]

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So we all know the ACEP policies regarding asymptomatic HTN. But what do you do when that screening comes back positive? Some proteinuria, very mild AKI, etc... Not much in the way of recs on that regard. Especially if the patient doesn't have any established f/u. Admit and subject them to a hefty inpatient bill(especially if uninsured)? Hope they followup in the standard 1-3 days? I've had this dilemma a few times recently since entering the "real world." Obviously not including the people with Cr of 5 and florid end-organ failure. As always thanks for the input.

 

[RoyBasch]

I find these patients are pretty easy to admit. Internists seem to be way more worried about hypertension than we are anyways. A lot of internist will admit someone for sufficiently high blood pressure even in the absence of ANY end organ dysfunction.

 

[bravotwozero]

First of all, EFF the patient bill. This is NOT your problem. Repeat after me "I AM NOT THE RESOURCE STEWARD. THE PATIENT BILL IS NOT MY EFFING PROBLEM'.

There is waaaay too much bullcrap that you have to deal with in your profession in this country to worry about this BS, such as patient complaints, massive amount of axis II psycopathology, med mal garbage. Do what you think you need to first to minimize a bad outcome, second to keep patients from whining.

Now that we've gotten that out of the way, No hard and fast rule here. If you want to be aggressive and minimize risk, go ahead and admit the patient and call it 'hypertensive urgency/emergency blah blah', especially if you don't get pushback from hospitalists and hospital beds are not an issue.

OR, you can just lower the BP, arrange for prompt outpatient PCP follow up and discharge home.

 

[thegenius]

So we all know the ACEP policies regarding asymptomatic HTN. But what do you do when that screening comes back positive? Some proteinuria, very mild AKI, etc... Not much in the way of recs on that regard. Especially if the patient doesn't have any established f/u. Admit and subject them to a hefty inpatient bill(especially if uninsured)? Hope they followup in the standard 1-3 days? I've had this dilemma a few times recently since entering the "real world." Obviously not including the people with Cr of 5 and florid end-organ failure. As always thanks for the input.

I send them home. They need help chronically. Their Cr 1.6, or they have proteinuria....or whatever....if they have no symptoms I send them home. I might start them on a med, depends on what they are taking or their situation.

You don't know if the 1.6 is new or old but it is very very very very likely old and slowly gone up over time to get to that point. And their BP 190/120? They have hypertensive nephrosclerosis. Admitting them isn't going to help. It's not like admitting them will get their Cr back to 1. What they need to do is take their medicines and see a doctor and take care of themselves. I usually tell them that they are slowly killing themself and before they know it, they will be on dialysis, go blind, or have a stroke and can't walk. These are generally IRREVERSIBLE

 

[VA Hopeful Dr]

I send them home. They need help chronically. Their Cr 1.6, or they have proteinuria....or whatever....if they have no symptoms I send them home. I might start them on a med, depends on what they are taking or their situation.

You don't know if the 1.6 is new or old but it is very very very very likely old and slowly gone up over time to get to that point. And their BP 190/120? They have hypertensive nephrosclerosis. Admitting them isn't going to help. It's not like admitting them will get their Cr back to 1. What they need to do is take their medicines and see a doctor and take care of themselves. I usually tell them that they are slowly killing themself and before they know it, they will be on dialysis, go blind, or have a stroke and can't walk. These are generally IRREVERSIBLE

Check a u/a before you send them home for me to deal with just to make sure it's not acute hypertensive nephrosclerosis if you don't mind.

 

[Groove]

The HTN Urgencies with equivocal nephropathy...I will generally send them home after a quick renal consult. I like to make sure nephrology can see them in a timely manner and make sure they are on board with the plan which bolsters my disposition from a medicolegal standpoint. If you're going to do this, you need to be prepared to easily identify any nephrotoxic medications on their med list to d/c and/or replace which can sometimes be a real hassle. That's for the borderline cases. If someone has BP over 200 and Cr 2.4 and no prior labs, it's not like those are difficult admits, at least for me. There's plenty of reason to admit those.

 

[Rekt]

The HTN Urgencies with equivocal nephropathy...I will generally send them home after a quick renal consult. I like to make sure nephrology can see them in a timely manner and make sure they are on board with the plan which bolsters my disposition from a medicolegal standpoint. If you're going to do this, you need to be prepared to easily identify any nephrotoxic medications on their med list to d/c and/or replace which can sometimes be a real hassle. That's for the borderline cases. If someone has BP over 200 and Cr 2.4 and no prior labs, it's not like those are difficult admits, at least for me. There's plenty of reason to admit those.

Is there even any evidence that phone consults add medicolegal protection? I can make a patient sound like anything over the phone. Wouldn't it just become a game of "Well he made the patient sound very stable and we'll appearing to me" etc. I find these calls probably the biggest time wastes in all of EM as I can't think of a single time I've had any meaningful input.

 

[Groove]

Is there even any evidence that phone consults add medicolegal protection? I can make a patient sound like anything over the phone. Wouldn't it just become a game of "Well he made the patient sound very stable and we'll appearing to me" etc. I find these calls probably the biggest time wastes in all of EM as I can't think of a single time I've had any meaningful input.

Huge legal precedent. I've seen malpractice cases where the EP wasn't even sued and they went after the specialist instead, or cases where they dropped the EP and continued the suit against the specialist. Remember, they can say whatever they want but in the end you're the only one with a documented discussion memorializing the conversation in your note. That's gold. In fact, if you find some grumpy specialists who seem to absolutely hate any and all EPs that call them, yet you can never figure out why? They might have been sued from an ED note where the EP dropped in their name and threw them under the bus on a questionable disposition. Nothing is guaranteed of course, but do documented consults give you an element of medicolegal protection? Absolutely.

 

[southerndoc]

Is there even any evidence that phone consults add medicolegal protection? I can make a patient sound like anything over the phone. Wouldn't it just become a game of "Well he made the patient sound very stable and we'll appearing to me" etc. I find these calls probably the biggest time wastes in all of EM as I can't think of a single time I've had any meaningful input.

All of our phone calls are recorded (we use PerfectServe to directly communicate with anyone on call -- APP or physician). Highly recommend it to any health system considering a central source to figure out who is on call, allow texting/calls between physicians, and to allow nurses to text physicians for orders. We do not allow the ED nurses to text docs via PerfectServe. Only admitted patients have that ability. Recordings of texts and phone calls are kept for 2 years, which is the Georgia statute of limitations.

 

[WilcoWorld]

First of all, EFF the patient bill. This is NOT your problem. Repeat after me "I AM NOT THE RESOURCE STEWARD. THE PATIENT BILL IS NOT MY EFFING PROBLEM'.

Given our current situation, I agree. “Ought implies can” so it’s absurd to say you have a duty to do something when you don’t have the ability to do that something.

Resource stewardship will be necessary to keep our healthcare system from swallowing up the GDP, but at present EPs are not given the tools we need to be stewards. Sigh

 

[turkeyjerky]

This is why I don't check UA's or BMPs on patients who come in with asymptomatic hypertension.

 

[Cinclus]

This is why I don't check UA's or BMPs on patients who come in with asymptomatic hypertension.

Same. I generally don't check anything if zero symptoms, but it is highly common that the MLP in triage has already ordered a full panel of checkery by the time the patient makes it back to me for their scary BP. Only ONCE since I have been an attending did they directly bring the patient to me with nothing ordered (nobody in the waiting room and beds were free). He was completely asymptomatic. I examined and reassured him. I prescribed a med. I made sure he had follow-up. Lightning-fast disposition.

 

[Druggernaut]

This is why I don't check UA's or BMPs on patients who come in with asymptomatic hypertension.

Agreed. If there's no prior labs for comparison, I don't know that it's acute. Medicine then takes the next logical step and says they have organ dysfunction and thus require acute lowering and the ICU for hypertensive emergency. Now we've really wasted resources and exposed the patient to potential harm.

 

[gro2001]

So we all know the ACEP policies regarding asymptomatic HTN. But what do you do when that screening comes back positive? Some proteinuria, very mild AKI, etc... Not much in the way of recs on that regard. Especially if the patient doesn't have any established f/u. Admit and subject them to a hefty inpatient bill(especially if uninsured)? Hope they followup in the standard 1-3 days? I've had this dilemma a few times recently since entering the "real world." Obviously not including the people with Cr of 5 and florid end-organ failure. As always thanks for the input.

I'd send them home. You haven't discovered a hypertensive emergency, you've found a natural consequence of their chronic disease. I also do the very unpopular thing among ED docs and prescribe them BP meds though to hold them over till they see a PCP. 5 mg amlodipine QD.

 

[carbonizedeyesockets]

This is why I don't check UA's or BMPs on patients who come in with asymptomatic hypertension.

I love asymptomatic hypertension complaints. I can usually write the note and prep DC paperwork before seeing them. 9 out of 10 times I return to the computer and order the discharge, sign my chart, and move on.

 

[thegenius]

Check a u/a before you send them home for me to deal with just to make sure it's not acute hypertensive nephrosclerosis if you don't mind.

I will be happy to send you all my referrals. You got open spots in your clinic? I’ve got lots of referrals. 🙂

 

[thegenius]

This is why I don't check UA's or BMPs on patients who come in with asymptomatic hypertension.

Right I was just going to ask who is ordering this stuff? You have chronic knee pain at 46 yrs old and BP is 200/104?

I’m not ordering labs but I am talking to them about their BP. Like did you know you have HTN ( yes / no ), are you on meds ( yes / no ), did you run out of them ( yes / no ), you use drugs ( yes / no ), do you even care ( yes / no ), etc....

 

[thegenius]

I'd send them home. You haven't discovered a hypertensive emergency, you've found a natural consequence of their chronic disease. I also do the very unpopular thing among ED docs and prescribe them BP meds though to hold them over till they see a PCP. 5 mg amlodipine QD.

I will sometimes do this too. Frankly most people who are 43 walking around with a BP of 190/125 are probably the least educated people in our society who have the poorest access to health care.

 

[VA Hopeful Dr]

I will be happy to send you all my referrals. You got open spots in your clinic? I’ve got lots of referrals. 🙂

Not many these days, just had a partner retire. Went from 16-18/day to 28-30/day overnight.

It's been fantastic.

 

[GeneralVeers]

I think there's more liability to ordering labs for these patients than not. If I order labs, then get that elevated CR, and send them home it represents more risk than not having the labs and document whey they weren't indicated.

 

[The Knife & Gun Club]

At what point do you all treat asymptotic HTN?

One of our sites holds strictly to not sending anyone home with a systolic over 200 regardless of symptoms - but I don’t really see why that would be any different than 190, and they’re just gonna bounce right back up to 200+ in 12 hours when the meds wear off...

 

[bravotwozero]

I'd send them home. You haven't discovered a hypertensive emergency, you've found a natural consequence of their chronic disease. I also do the very unpopular thing among ED docs and prescribe them BP meds though to hold them over till they see a PCP. 5 mg amlodipine QD.

The reason why prescribing BP meds is unpopular amongst EPs, is because the patient will go home, take their prescribed BP med, compulsively check their Blood Pressure, and then immediately come back to the ED stating that their 'Blood Pressure medications aren't working'. If I had a nickel for every time I see this kind of bounceback...

 

[GeneralVeers]

At what point do you all treat asymptotic HTN?

One of our sites holds strictly to not sending anyone home with a systolic over 200 regardless of symptoms - but I don’t really see why that would be any different than 190, and they’re just gonna bounce right back up to 200+ in 12 hours when the meds wear off...

What's their evidence for this, and who is monitoring it? Your institution is forcing you to treat something and cause potential harm?

 

[GeneralVeers]

Not lowering asymptomatic BPs was my number one source of complaints when I worked in TX. The primarily hispanic population is obsessed with their BP readings, and the older women often take their own BP multiple times a day for unclear reasons.

 

[carbonizedeyesockets]

I'm curious, though. Is there a BP at which point you think it could be too risky to send home and not intervene upon even if asymptomatic. Of course, I break "risk" in to 2 categories - risk of actual harm to patient, and risk of litigation should something, by chance, bad happen in the next week or so that someone could conceivably attribute to the blood pressure (e.g. stroke, MI, walk out the door and trip over a curb and hit their head and return with a SAH, etc.)

I pause when systolic is 230-240 or higher. I had one guy sitting around 260 consistently and I broke down and played up the hypertensive urgency thing and got him a bed (there was also no way he was going to get follow-up in any reasonable amount of time, and that would be assuming he could even schedule an appointment by himself since he had significant psychiatric issues and was living in a halfway home).

 

[thegenius]

Check a u/a before you send them home for me to deal with just to make sure it's not acute hypertensive nephrosclerosis if you don't mind.

Wait a second. I just glossed this over. So if the pt has, say hematuria and elevated BP and Cr, is the expectation that I'm to admit them?
The treatment is the same...they need their BP to slowly come down (not quickly)

 

[AlmostAnMD]

Okay I am starting to get outside of my knowledge base here, but I thought he was saying there could be grams of protein in the urine with acute kidney injury, r/o long bad things I can't spell but need steroids and biopsies

 

[Rekt]

Okay I am starting to get outside of my knowledge base here, but I thought he was saying there could be grams of protein in the urine with acute kidney injury, r/o long bad things I can't spell but need steroids and biopsies

Microproteinuria/proteinuria is usually first sign of kidney disease. First to show before creatinine changes and probably any meaningful GFR changes. Essentially CKD.

Hematuria in this setting would be more akin to a malignant hypertension/hypertensive emergency.

 

[VA Hopeful Dr]

Microproteinuria/proteinuria is usually first sign of kidney disease. First to show before creatinine changes and probably any meaningful GFR changes. Essentially CKD.

Hematuria in this setting would be more akin to a malignant hypertension/hypertensive emergency.

Exactly this.

 

[VA Hopeful Dr]

Wait a second. I just glossed this over. So if the pt has, say hematuria and elevated BP and Cr, is the expectation that I'm to admit them?
The treatment is the same...they need their BP to slowly come down (not quickly)

Admission is up to you and your hospitalist, but if there is no hematuria I'd be 100% OK with you not doing anything besides discharging the patient. If there is hematuria, on the other hand, there is a decent chance the kidney injury is more acute and if you don't admit them then at least discharge them with a BP med.

 

[Groove]

I get more BMPs on my HTN Urgencies than most of you I would wager. However, I'm in a horrible pt population where ESRD and DM2 is king. I have more obese, young people under 35 on dialysis than I've ever seen in my life. None of these pt's are particularly motivated and they all have some difficulty getting in to see their PCP in a timely manner upon discharge, so I will check kidney function on occasion. I like to think I prolong dialysis on some of them by a few years but who knows. That being said, I'm well aware of the ACEP policy on asymptomatic hypertension but I choose to apply liberal common sense.

I've caught enough new onset DM2 and AKI/CKD that it keeps me sufficiently superstitious enough to keep ordering them.

 

[Apollyon]

new onset DM2

Huh? How can you tell?

 

[thegenius]

Its a clinical one. Their sugar is 450, either you run an A1c or not (I do because we get them back in 1 hr and I like numbers), and then when you drill down on their symptoms, they actually have been thirsty for many months, peeing more than usual, tired, weak, headaches, etc. plus most diabetes in this country is insulin resistance rather than autoimmune, which is type 1.

 

[Apollyon]

Its a clinical one. Their sugar is 450, either you run an A1c or not (I do because we get them back in 1 hr and I like numbers), and then when you drill down on their symptoms, they actually have been thirsty for many months, peeing more than usual, tired, weak, headaches, etc. plus most diabetes in this country is insulin resistance rather than autoimmune, which is type 1.

That's not "new onset", unless one is using a different scale. Maybe "initial diagnosis" is better? Type 2 doesn't lose weight, going from 200lbs to 117lbs, being visibly sick, or ketotic and life-threateningly acidotic. (Ask me how I know.)
My point is, though, how can you tell? The A1c is a 120 day window, but, you don't know before that.

And, yes, I know about DM. 30 years ago, 95% of DM in the US was type 1. Now, 30 years later, 95% is type 2. That's why you have Januvia and Ozempic.

 

[Groove]

Huh? How can you tell?

Type 2 Diabetes ADA Diagnosis Criteria
Diagnostic criteria by the American Diabetes Association (ADA) include the following: [1]

• A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, or
• A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), or
• A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, or
• 
  
• A hemoglobin A1c (HbA1c) level of 6.5% (48 mmol/mol) or higher

 

[Apollyon]

Type 2 Diabetes ADA Diagnosis Criteria
Diagnostic criteria by the American Diabetes Association (ADA) include the following: [1]

• A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, or
• A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), or
• A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, or
• 
  
• A hemoglobin A1c (HbA1c) level of 6.5% (48 mmol/mol) or higher

I guess it's semantics. My question isn't how you diagnose it. It's how you know it's "new onset".

 

[Groove]

I guess it's semantics. My question isn't how you diagnose it. It's how you know it's "new onset".

Maybe I'm misunderstanding you? I mean, if you look back and their glucose was normal last visit and now they have any of those diagnostic criteria above, why would you have a problem calling it new onset diabetes? Even if they are a new pt....if they tell you they have never been diagnosed with diabetes and have been to a doctor in the last couple of years with blood work that was reportedly "normal", I still would take them at their word and call it new onset. I even have tons of "pre-diabetes" pt's who have clearly veered into full blown DM territory. Hell, I see so much diabetes where I'm at, it makes me want to buy an accucheck and start taking metformin just to fit in.

 

[Rendar5]

agreed. New onset means it wasn’t there last time someone looked. It doesn’t mean acute

 

[thegenius]

I get more BMPs on my HTN Urgencies than most of you I would wager. However, I'm in a horrible pt population where ESRD and DM2 is king. I have more obese, young people under 35 on dialysis than I've ever seen in my life. None of these pt's are particularly motivated and they all have some difficulty getting in to see their PCP in a timely manner upon discharge, so I will check kidney function on occasion. I like to think I prolong dialysis on some of them by a few years but who knows. That being said, I'm well aware of the ACEP policy on asymptomatic hypertension but I choose to apply liberal common sense.

I've caught enough new onset DM2 and AKI/CKD that it keeps me sufficiently superstitious enough to keep ordering them.

I'm Ok with all of that, you are helping your community.

 

[Groove]

You know, it's been kind of fun for me. I've been reading more about managing chronic HTN and pros/cons of all the various drug classes and what age/ethnicity/etc.. are best suited for which particular drugs, etc.. I was never particularly interested in any of this until my SO started working as a PCP and started coming home spouting off all these guidelines and "can you believe he hadn't ordered a micro albumin level in 5 years?! 5 YEARS!" and I'm going "Yeah...well...neither have I!". Same thing with diabetes. Considering that most of us have EM mastered after a few years, it's been fun learning new things. I must have spent 2 days re-reading some of the sections on HTN in Uptodate. ALLHAT trials, ACCOMPLISH trials, sequential mono therapy, blah blah blah. Most of us never learned any of this stuff in residency and after COVID it has become increasingly apparent to me just how much people rely on the ER for basic "primary care". If we truly saw 80% of what we were trained to deal with in residency, half of us would be out of a job. After the COVID drought, I've completely stopped being annoyed by all of the PCP complaints and suddenly started taking an interest. Sure, It's certainly not indicated most of the time, but it doesn't take me very long to tweak a few of their meds or add/subtract new/old ones. Hell, an A1C comes back in 10 minutes for me. If I anticipate a new diagnosis of DM, I just call down to the lab and ask them to add on an A1C. By the time I see a new pt and get back to my computer, the A1C is back. It's been kind of fun.

Maybe I'm just getting bored at this stage in my career. Who knows.

 

[thegenius]

You know, it's been kind of fun for me. I've been reading more about managing chronic HTN and pros/cons of all the various drug classes and what age/ethnicity/etc.. are best suited for which particular drugs, etc.. I was never particularly interested in any of this until my SO started working as a PCP and started coming home spouting off all these guidelines and "can you believe he hadn't ordered a micro albumin level in 5 years?! 5 YEARS!" and I'm going "Yeah...well...neither have I!". Same thing with diabetes. Considering that most of us have EM mastered after a few years, it's been fun learning new things. I must have spent 2 days re-reading some of the sections on HTN in Uptodate. ALLHAT trials, ACCOMPLISH trials, sequential mono therapy, blah blah blah. Most of us never learned any of this stuff in residency and after COVID it has become increasingly apparent to me just how much people rely on the ER for basic "primary care". If we truly saw 80% of what we were trained to deal with in residency, half of us would be out of a job. After the COVID drought, I've completely stopped being annoyed by all of the PCP complaints and suddenly started taking an interest. Sure, It's certainly not indicated most of the time, but it doesn't take me very long to tweak a few of their meds or add/subtract new/old ones. Hell, an A1C comes back in 10 minutes for me. If I anticipate a new diagnosis of DM, I just call down to the lab and ask them to add on an A1C. By the time I see a new pt and get back to my computer, the A1C is back. It's been kind of fun.

Maybe I'm just getting bored at this stage in my career. Who knows.

You'll be a better doctor for it too.

 

[DocEspana]

At what point do you all treat asymptotic HTN?

One of our sites holds strictly to not sending anyone home with a systolic over 200 regardless of symptoms - but I don’t really see why that would be any different than 190, and they’re just gonna bounce right back up to 200+ in 12 hours when the meds wear off...

300

If you can show me 300, i'll get interested.

I do cater the amount of talking I do to the absurdity of the BP though. 180 systolic just gets the "take your damn meds" routine. 210? I'm gonna actually call their PCP (if its a day shift) and make sure there really is prompt follow up. mid 200s? I might might actually even get a pmhx rather than just copying and pasting the nurse report of pmhx.

my community is largely old haitian women though. clocking 250s systolic and actively crocheting in the ED totally surprised to hear they have htn is pretty common. If I tried to treat their BP, there would be a national shortage of labetalol and hydralazine by the end of the week.

 

[thegenius]

300

If you can show me 300, i'll get interested.

I do cater the amount of talking I do to the absurdity of the BP though. 180 systolic just gets the "take your damn meds" routine. 210? I'm gonna actually call their PCP (if its a day shift) and make sure there really is prompt follow up. mid 200s? I might might actually even get a pmhx rather than just copying and pasting the nurse report of pmhx.

my community is largely old haitian women though. clocking 250s systolic and actively crocheting in the ED totally surprised to hear they have htn is pretty common. If I tried to treat their BP, there would be a national shortage of labetalol and hydralazine by the end of the week.

never seen 300 in my life...highest is like 260-265. And surprisingly she was asymptomatic.

 

[southerndoc]

never seen 300 in my life...highest is like 260-265. And surprisingly she was asymptomatic.

Once had a head bleed that measured 300 on the cuff. I put an A-line in and he was at 340.

Supposedly one of the cardiothoracic surgeons did a study looking at pressures in powerlifters (they have a higher incidence of aortic dissections). He obtained readings of 4-500 with deadlifts and squats.

 

[thegenius]

Once had a head bleed that measured 300 on the cuff. I put an A-line in and he was at 340.

Supposedly one of the cardiothoracic surgeons did a study looking at pressures in powerlifters (they have a higher incidence of aortic dissections). He obtained readings of 4-500 with deadlifts and squats.

Now that is an emergency, an IPH with a BP of 340. I've always wondered if I would ever start nitroprusside on anybody for legit purposes and that would be a case right there.

 

[WheezyBaby]

Once had a head bleed that measured 300 on the cuff. I put an A-line in and he was at 340.

Supposedly one of the cardiothoracic surgeons did a study looking at pressures in powerlifters (they have a higher incidence of aortic dissections). He obtained readings of 4-500 with deadlifts and squats.

I thought the number was in the 300's, but maybe that was the mean/median, impressive nonetheless, obviously without ill effects.

My record is also <300, about 280 in an ischemic CVA

Now that is an emergency, an IPH with a BP of 340. I've always wondered if I would ever start nitroprusside on anybody for legit purposes and that would be a case right there.

I used nipride once for a sick heart while on call. The pharmacy called me postcall to let me know I needed to find another option because the little bit of nipride I used overnight was the hospital's entire supply and when the infusion ran out in 30 min it was done-zo unless we got more from one of our other hospitals. Appreciate the 30 minute heads up to figure out and implement a new game plan pharmacy. Worked great though.

 

[turkeyjerky]

How would you guys manage the following patient?

mid-60s lady comes in via EMS for chest pain. Received NTG en route w/o significant change. MAP persistantly in the 130s. She looks completely comfortable but has ongoing central chest pressure. Has a long history of resistant hypertension (last visit was two years ago for visual changes and her pressure was 250/90 then) but states it had been pretty well controlled until she ran out of her meds a month ago. EKG shows LVH w/ lateral ST depression and TWI (looks like lvh w/ strain but no previous to compare). CXR shows some cardiomegaly w/o any other signs of failure and trop (high sens) is negative.

 

[bravotwozero]

elevated BP and chest pain? gotta rule out badness man. CTA for dissection rule out.

 

[turkeyjerky]

elevated BP and chest pain? gotta rule out badness man. CTA for dissection rule out.

I thought about it, but she looked fine, pain was gradual in onset, non-migratory and had symmetric pulses, so I didn't pursue it further.

 

[GatorCHOMPions]

elevated BP and chest pain? gotta rule out badness man. CTA for dissection rule out.

Do you CTA every comfortable appearing patient with chest pain and elevated BP? Seems like overkill to me.