3. MEDICAL EMERGENCIES

3.8 HYPERTENSIVE EMERGENCIES

A hypertensive emergency is characterized by a rapid and severe elevation of a patient's diastolic BLOOD PRESSURE (greater than 115 mm Hg-130 mm Hg) which will lead to significant, irreversible end-organ damage within hours if not treated. The brain, heart and kidneys are at risk. The patient may also present with restlessness, confusion, blurred vision, nausea and vomiting.

Hypertensive emergencies may include any of the following conditions in the presence of a diastolic BLOOD PRESSURE greater than 115-130: myocardial ischemia, aortic dissection, pulmonary edema, hypertensive intracranial hemorrhage, toxemia of pregnancy and hypertensive encephalopathy.

Hypertensive encephalopathy is a true emergency and is the direct result of untreated hypertension. It is characterized by severe headache, vomiting, visual disturbances (including transient blindness), paralysis, seizures, stupor, and coma. This condition may lead to pulmonary edema, left ventricular failure or cardiovascular accident (CVA).

The goal of therapy for hypertensive emergencies is to reduce the BLOOD PRESSURE, on average, approximately 10% - 20% or until patient's clinical presentation is improved. Caution should be taken to reduce the BLOOD PRESSURE in a controlled fashion as opposed to rapid reduction.

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway and assist ventilations as needed.

3. Administer high concentration oxygen via non-rebreather mask.

4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs.

5. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies, Substance abuse or Trauma (recent head injury).

TREATMENT

BASIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Assist ventilations as needed.

3. Administer high concentration of oxygen by non-rebreather mask.

4. Activate ALS intercept, if deemed necessary and if available.

5. Initiate transport as soon as possible with or without ALS.

6. Notify receiving hospital.

INTERMEDIATE PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Assist ventilations as needed.

3. Administer high concentration of oxygen by non-rebreather mask.

4. ALS STANDING ORDERS

a. Provide advanced airway management (endotracheal intubation), if indicated.

b. Initiate IV Normal Saline (KVO) or Saline Lock while in transport.

5. Activate Paramedic intercept, if deemed necessary and if available.

6. Initiate transport as soon as possible with or without Paramedics.

7. Notify receiving hospital.

PARAMEDIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Assist ventilations as needed.

3. Administer high concentration of oxygen by non-rebreather mask.

4. ALS STANDING ORDERS

a. Provide advanced airway management (endotracheal intubation), if indicated.

b. Cardiac monitor / dysrhythmia recognition: manage per protocol.

c. Initiate IV Normal Saline (KVO) or Saline Lock while in transport.

5. Initiate transport as soon as possible.

6. Contact MEDICAL CONTROL. The following may be ordered:

a. Administer Nitroglycerine (NTG) 0.4 mg (1/150 gr.) tablet or spray SL if diastolic BLOOD PRESSURE is greater than 115 mmHg to 130 mmHg. NTG may be repeated in five (5) minute intervals x two (2) as dictated by patient's BLOOD PRESSURE. May also administer Nitropaste, 1" to anterior chest wall. NOTE: Administration of Nitroglycerin is contraindicated if patient has taken Viagra TM within the last 12 hours.

b. Morphine Sulfate 2 mg to 5 mg IV push.

c. Furosemide (Lasix) 0.5 mg/kg - 1.0 mg/kg IV push (SLOWLY) for patients presenting with congestive heart failure (CHF) or pulmonary edema.

d. Nifedipine 10 mg sublingual (1 capsule; puncture capsule first) for patients with hypertensive crisis and angina. Option: Nifedipine 10-20 mg P.O.

CONTRAINDICATIONS: presence of second or third degree heart blocks or evidence of recent cerebrovascular accident (CVA).

7. Notify receiving hospital.






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