Wednesday, December 2, 2009

raising my blood pressure

One of the commonest traps for young players is the urgent treatment of blood pressure.  There is a lot of pressure from non medically trained people (especially nursing staff) to pay attention to hypertension.  On one of my  after-hours shifts during the start of internship, a job was left in the book regarding a patient's blood pressure of 170/90.  I glanced at it, said hi to the patient, and crossed the job off.  Thirty minutes later it was rewritten in the doctors' jobs book.  I crossed it off again and went off to theatre.  Just after the case, I was paged with an angry accusation that i was crossing off jobs without actually doing them.  I said that I didn't really care about a blood pressure of that level.  I later saw that an entry had been made in the patient's notes:  "BP 170/90.  Dr paged and said 'I don't care.'".  At this point I learnt the essential order of internship:  "treat the notes, then treat the nurse, then treat the patient".

The first thing to realise is that there is little need to treat a number overnight.  Go and see the patient and assess them for end organ damage:  when called, ask for an ECG and a urinalysis.  Headache does not count as end organ damage, but encephalopathy does;  you must distinguish hypertensive encephalopathy from delirium, dementia, or other causes of AMS.

If the patient is alert and orientated, not in distress, and pain free, you are home and hosed.  It is not a hypetensive emergency.  Write in the notes:

ATSP re BP 180/80.  A&Ox3.  No signs of target organ damage.

Plan:  team r/v mane.

Otherwise call for help.

Everyone has a number that they will treat.  I joke that my number is "10 more than what the patient has", but in reality it is somewhere around 200-220.  In this situation, giving a dose of something safe makes everyone feel good.  I like DHP CCBs;  there are no real contraindications, they work well, and are now off patent.  Cardiovascular Guidelines 2008 suggests amlodipine 5-10mg as the top of the list, and I'm too illiterate to read the rest of the list, although I hear that there's an ACEI somewhere there too.

The only reasons to use nitroglycerin (other than a bomb threat) are myocardial ischaemia and pulmonary oedema, which come under "target organ damage" above.  All it does is raise my blood pressure when I see it in the morning.

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