HTN in the ED

[winterallsummer]

I am beginning in the ED and OBS unit and had a quick question for seasoned PAs.  The pts in the OBS can hang around for ~18 hrs for various disorders (COPD, CP, PNA, etc etc) and commonly have SBP > 160-180.  I wanted to know what is a good general approach to this.

 

When is it time to tx these pts?  When is it okay to "ignore" the HTN?  Sometimes these pts are going to get stress tested and need to fall below certain parameters.

 

I know HTN in the ED is classically taught to be linked to stress, pain etc however there is in fact a correlation between HTN in the ED and out-pt.  Obviously not all cases can be ignored and chalked down to pain, stress, etc.  Also I do know to look for end organ damage (emergent HTN) which calls for quick action.

 

Besides putting pts on their home meds, what else are your guys go to meds or strategies?  Do you avoid BBlocker use due to SEs?  Is hyrdalazine 10-25 mg prn a safe bet?  .1 Clonidine?  Are you ever using ACEi's in these scenarios or other more "long term" meds you can send them out with a short Rx for (+ f/u)?

 

I am mostly referring to pts who come in for COPD or some other chronic condition and are hypertensive on top of this and when to tx and meds of choice, not so much the pt who comes in with a fracture but no hx of HTN, etc.

 

http://hyper.ahajournals.org/content/57/1/18.full

[EMEDPA]

Unless they have significant sx or evidence of end organ damage, we generally give them a bp card and have them f/u with their pcp. a single elevated bp( or a few in the obs unit) in the ER without sx does not merit aggressive tx.

If the pt has a hx of htn give them their home med at nl dose. If the pt has a hx of htn and is out of meds, give them the med and dose they last took and an rx for a 1 month supply.

if someone has a ridiculous bp with sx (h/a, visual changes, etc) then lowering the bp gradually is appropriate. any of multiple strategies are appropriate. some folks use nitrates, some use clonidine, others use B-blockers or labetalol for folks not needing a stress test. some folks use nicardipine 5 mg/hr, titrate to effect. lots of options out there.

[ohiovolffemtp]

Is there a concern with use of clonidine that the drop in BP is temporary?  In other words, the number gets better, but shortly after discharge the patient is back to the same levels?

 

Also, for the patients without a PCP (most of mine), a referral to the local clinic typically doesn't mean that they'll ever be seen.  Patients' initiative to follow-up tends to be poor.  Which is preferrable: leave with the referral knowing that follow-up is unlikely, or 30 day supply of a starting dose of an ACEI or HCTZ?

[EMEDPA]

Is there a concern with use of clonidine that the drop in BP is temporary?  In other words, the number gets better, but shortly after discharge the patient is back to the same levels?

 

Also, for the patients without a PCP (most of mine), a referral to the local clinic typically doesn't mean that they'll ever be seen.  Patients' initiative to follow-up tends to be poor.  Which is preferrable: leave with the referral knowing that follow-up is unlikely, or 30 day supply of a starting dose of an ACEI or HCTZ?

if bp is high enough that they are symptomatic and getting clonidine in the ED and if they are not admitted then I wouldn't mess around with HCTZ. that ain't going to do it as monotherapy for folks with significant symptomatic htn.

I would start most of these folks on a calcium channel blocker + daily 81 mg asa . obviously talk to them about salt restriction, diet, exercise, etc as well.  If you start an ACEI you really need baseline labs and f/u labs in a few weeks. If you can't assure f/u. you don't want to start something that might toast their kidneys and/or make them hypekalemic. I know what you mean about f/u for new pts. In my town the only clinic that takes medicaid is 3 months out for new pts and 5 weeks out for established pts. That basically means they don't have a pcp even when assigned there.

[medic25]

Is there a concern with use of clonidine that the drop in BP is temporary?  In other words, the number gets better, but shortly after discharge the patient is back to the same levels?

 

This; I think in general if you're giving clonidine for asymptomatic hypertension, the only benefit is that it makes you or your nursing staff feel better before discharging the patient.  If you aren't already familiar with it, I'd suggest reviewing the ACEP clinical policy for ED management of asymptomatic elevated blood pressure. 

 

http://www.acep.org/clinicalpolicies/

[winterallsummer]

If a pt is not going to fu w PCP anyway, what, realistically, is the benefit of giving them 30 days of BP meds? I agree it is worth a try and may give them more motive to control their chronic health issue, but is it worth worrying about side effects of a ccb if they only take it for thirty days?

 

I have been using 180-190 as a cutoff to give prn clonidine or bblocker but maybe I should just reassure nursing it is permissible. My problem is in PTs who claim they are normally 130/80 and won't drop below 180/100 even after 8h and two sets of vitals in the obs.

[True Anomaly]

If a pt is not going to fu w PCP anyway, what, realistically, is the benefit of giving them 30 days of BP meds? I agree it is worth a try and may give them more motive to control their chronic health issue, but is it worth worrying about side effects of a ccb if they only take it for thirty days?

 

I have been using 180-190 as a cutoff to give prn clonidine or bblocker but maybe I should just reassure nursing it is permissible. My problem is in PTs who claim they are normally 130/80 and won't drop below 180/100 even after 8h and two sets of vitals in the obs.

 

You can use that argument with just about any chronic med being given from the ER- if they don't have anyone to follow up with, giving them a rx is only going to take money out of their pocket.  

 

There's two parts to the problem- 1. they don't have a PCP to follow up with when they actually want one;  2.they don't care to follow up with anyone.  

 

For problem one, I at least have a resource for those who do have insurance- I can get them plugged in to a PCP and if so then I believe it's entirely appropriate to provide them with a prescription to bridge them to that appointment that has been set up.  If they don't have insurance and they want a PCP, we refer them to the county health system and they may or may not get an appointment- I may or may not provide a prescription because it will be additional money out of their pocket with no discernible health benefit.

 

If I encounter problem two and they definitely don't have a PCP to follow up with, then I'm sorry but I'm not giving them a prescription.  We all know when we encounter a patient like this- you'll talk until you are blue in the face and they'll hear none of it, or come up with 17 different excuses as to why they can't/won't see anyone, and if I can't help work through their problems by discussing it and they're still throwing out excuses, then I'm going to move on to the next patient who actually wants help.  I very much respect a patient's decision on their own healthcare, and I default to "My job is to make medical recommendations- you are free to do whatever you'd like with the information"

 

Sorry for the slight off-topic spin.  In regards to your situation with a HTN patient, I think it's a different story when you encounter the patient in an ER vs an obs setting.  ER has good guidelines that medic25 posted when the patient is truly asymptomatic.  The Obs unit is a different story- I would look more towards internal medicine guidelines for admitted patients being discharged with hypertension, if such guidelines exist.  I'll be honest- at my old job where I would have to cover an obs unit, we'd generally discharge them without adding additional BP meds because most of them had follow up with a PCP who would work with them on BP meds anyway- we just deferred to them.

 

And I only use clonidine in the ER when someone is coming in for an opiate withdrawal or a patient I'm going to admit already takes clonidine and missed a dose.

[medic25]

 

And I only use clonidine in the ER when someone is coming in for an opiate withdrawal or a patient I'm going to admit already takes clonidine and missed a dose.

 

 

Agreed; I haven't used clonidine in years outside of these indications.  

[EMEDPA]

Agreed; I haven't used clonidine in years outside of these indications.  

I like using clonidine patches for the withdrawal crowd. learned a few years ago that the tabs have street value and can be exchanged for drugs...

[winterallsummer]

Thanks for all the replies.  What happens sometimes in obs is pt comes in ED SBP > 200, gets hit with clonidine or labetolol or less likely hydralazine, admit to obs and of course SBP quickly is > 200 again, or 180 or whatever.  Since these pts are in obs and not ED at this point, if it is asymptomatic HTN I will titrate up on their BP meds if at all possible or get them their BP meds if they missed a dose, or if they are already maxed out or taking none, look for appropriate PO options.  Symptomatic HTN then I will use these BBlocker or hydralzine or clonidine sure, but then there has to be a plan to tx some underlying problem - or these pts are just chronically uncontrolled and this is just a temporary fix until another PO med is added.  Otherwise I will go up on their ACEi, etc, and within a couple sets of vitals they are in control and there is not a big withdrawal.  Then I can send them home with a higher dose of whatever BP med for 1 week and refer to PCP f/u, or just have them f/u w/ PCP if I felt they are not necessarily chronically > 170 and they were just high in the hospital.

 

It has really made me second guess giving clonidine in the ER, although I see many people doing this on pts coming in with SBP > 200 and then they are discharge with SBP 160-70s but of course it is going to jump right back up.