1、Hypertension and Peripheral Vascular Disease,EMS Professions Temple College,Hypertension,Resting BP consistently 140 systolic or 90 diastolic,Epidemiology,20% of adult population 35,000,000 people 25% do not know they are hypertensive Twice as frequent in blacks than in whites 25% of whites and 50%
2、of blacks 65 y/o,Types,Primary (essential) hypertension Secondary hypertension,Primary Hypertension,85 - 90% of hypertensives Idiopathic More common in blacks or with positive family history Worsened by increased sodium intake, stress, obesity, oral contraceptive use, or tobacco use Cannot be cured,
3、Secondary Hypertension,10 - 15% of hypertensives Increased BP secondary to another disease process,Secondary Hypertension,Causes: Renal vascular or parenchymal disease Adrenal gland disease Thyroid gland disease Aortic coarctation Neurological disorders Small number curable with surgery,Hypertension
4、 Pathology,Increased BP inflammation, sclerosis of arteriolar walls narrowing of vessels decreased blood flow to major organs Left ventricular overwork hypertrophy, CHF Nephrosclerosis renal insufficiency, failure,Hypertension Pathology,Coronary atherosclerosis AMI Cerebral atherosclerosis CVA Aorti
5、c atherosclerosis Aortic aneurysm Retinal hemorrhage Blindness,Signs/Symptoms,Primary hypertension is asymptomatic until complications develop Signs/Symptoms are non-specific Result from target organ involvement Dizziness, flushed face, headache, fatigue, epistaxis, nervousness are not caused by unc
6、omplicated hypertension.,HTN Medical Management,Life style modification Weight loss Increased aerobic activity Reduced sodium intake Stop smoking Limit alcohol intake,HTN Medical Management,Medications Diuretics Beta blockers Calcium antagonists Angiotensin converting enzyme inhibitors Alpha blocker
7、s,HTN Medical Management,Medical management prevents or forestalls all complicationsPatients must remain on drug therapy to control BP,Categories of Hypertension,Hypertensive Emergency (Crisis) acute BP with sx/sx of end-organ injury Hypertensive Urgency sustained DBP 115 mm Hg w/o evidence of end-o
8、rgan injury Mild Hypertension DBP 90 but 115 mm Hg w/o symptoms Transient Hypertension elevated due to an unrelated underlying condition,Hypertensive Crisis,Acute life-threatening increase in BPUsually exceeds 200/130,Hypertensive Crisis,Few Hypertensive Conditions are “Emergencies” Emergent Hyperte
9、nsive Conditions include: encephalopathy (CNS sx/sx) eclampsia when associated with AMI or Unstable angina Acute renal failure Intracranial injury Acute LVF Aortic dissection,Causes,Sudden withdrawal of anti-hypertensives Increased salt intake Abnormal renal function Increase in sympathetic tone Str
10、ess Drugs Drug interactions Monoamine oxidase inhibitors Toxemia of pregnancy,Signs/Symptoms,Restlessness, confusion, AMS Vision disturbances Severe headache Nausea, vomiting,Seizures Focal neurologic deficits Chest pain Dyspnea Pulmonary edema,Hypertensive Crisis Can Cause,CVA CHF Pulmonary edema A
11、ngina pectoris AMI Aortic dissection,Hypertensive Crisis Management,Immediate goal: lower BP in controlled fashion No more than 30% in first 30-60 mins Not appropriate in all settings Oxygen via NRB Monitor ECG IV NS TKO Drug Therapy Targeted at simply lowering BP, OR Targeted at underlying cause,Dr
12、ug Therapy Possibilities,Sodium Nitroprusside (Nipride) Potent arterial and venous vasodilator Vasodilation begins in 1 to 2 minutes 0.5 g/kg/min by continuous infusion, titrate to effect increase in increments of 0.5 g/kg/min 50 mg in 250 cc D5W Effects easily reversible by stopping drip Continuous
13、 hemodynamic monitoring required Cover IV bag/tubing to avoid exposure to light Used primarily when targeting lower BP only,Drug Therapy Possibilities,Nitroglycerin Vasodilator Nitropaste simplest method 1 to 2 inches of ointment q 8 hrs easy to control effect but slow onset Sublingual NTG is faster
14、 route 0.4 mg SL tab or spray q 5 mins easy to control but short acting NTG infusion, 10 - 20 mcg/min seldom used for hypertensive crisis Commonly used prehospital when targeting BP lowering only especially in AMI,Drug Therapy Possibilities,Nifedipine (Procardia) Calcium channel blocker Peripheral v
15、asodilator 10 mg Sublingual Split capsule longitudinally and place contents under tongue or puncture capsule with needle and have patient chew Used less frequently today! Frequently in past! Concern for rapid reduction of BP resulting in organ ischemia,Drug Therapy Possibilities,Furosemide (Lasix) L
16、oop Diuretic initially acts as peripheral vasodilator later actions associated with diuresis 40 mg slow IV or 2X daily dose most useful in acute episode with CHF or LVF Often used with other agents such as NTG,Drug Therapy Possibilities,Hydrazaline (Apresoline) Direct smooth muscle relaxant relax ar
17、terial smooth muscle venous 10-20 mg slow IV q 4-6 hrs; initial dose 5 mg for pre-eclampsia/eclampsia Usually combined with other agents such as beta blockers concern for reflex sympathetic tone increase Most useful in pre-eclampsia and eclampsia,Drug Therapy Possibilities,Metoprolol (Lopressor), or
18、 Labetalol (Normodyne) decrease in heart rate and contractility Dose Metoprolol: 5 mg slow IV q 5 mins to total 15 mg Labetalol: 10-20 mg slow IV q 10 mins Metoprolol is selective beta-1 minimal concern for use in asthma and obstructive airway disease Labetalol: both alpha & beta blockade Most usefu
19、l in AMI and Unstable angina,Hypertensive Crisis Management,Avoid crashing BP to hypotensive or normotensive levels!Ischemia of vital organs may result!,Hypertensive Crisis Management,Must assure underlying cause of BP is understood HTN may be helpful to the patient Aggressive treatment of HTN may b
20、e harmful,What patients may have HTN as a compensatory mechanism?,Syncope,Sudden, temporary loss of consciousness caused by inadequate cerebral perfusion,Vasovagal Syncope,Simple fainting occurring when upright Increased vagal tone leads to peripheral vasodilation, bradycardia which lead to: Decreas
21、ed cardiac output Decreased cerebral perfusion Causes Fright, trauma, pain Pressure on carotid sinus (tight collar, shaving),Cardiogenic Syncope,Paroxysmal Tachyarrhythmias (atrial or ventricular) Bradyarrhythmias Stokes-Adams attack Valvular disease especially aortic stenosis Can occur in any posit
22、ion,Postural Syncope,Due to decreased BP on standing or sitting upOrthostatic hypotension,Postural Syncope,Drugs - usually antihypertensives Diuretics Vasodilators Beta-blockers Volume depletion Acute hemorrhage Vomiting or diarrhea Excessive diuretic use Protracted sweating Neuropathic diseases - d
23、iabetes,Tussitive Syncope,Coughing Increased intrathoracic pressure Decreased venous return Vagal stimulation Decreased heart rate,Micturation Syncope,Urination Increased vagal tone Decreased cardiac output Frequently associated with Volume depletion due to EtOH Vasodilation due to EtOH,Syncope Hist
24、ory,What were you doing when you fainted? Did you have any warning symptoms? Have you fainted before? Under what circumstances?Any history of cardiac disease? Any medications? Any other past medical history?,Syncope Management,Supine position - possibly elevate lower extremities Do not sit up or mov
25、e to semi-sitting position quickly Airway - oxygen via NRB Loosen tight clothing,Syncope Management,Vital signs, Focused Hx & Physical exam Assess for injuries sustained in fall Attempt to identify cause Based on history/physical, Consider: ECG Monitor Blood glucose check Vascular access Transport f
26、or further evaluation,Peripheral Vascular Disease,Peripheral Atherosclerotic Disease Deep Vein Thrombophlebitis Varicose Veins,Peripheral Atherosclerosis,Gradual, progressive disease Common in diabetics Thin, shiny skin Loss of hair on extremities Ulcers, gangrene may develop,Peripheral Atherosclero
27、sis,Intermittent Claudication Deficient blood supply in exercising muscle Pain, aching, cramps, weakness Occurs in calf, thigh, hip, buttocks on walking Relieved by rest (2 - 5 minutes),Peripheral Atherosclerosis,Acute Arterial Occlusion Sudden blockage by embolism, plaque, thrombus Can result from
28、vessel trauma The 5 Ps of acute occlusion Pain, worsening over several hours Pallor, cool to touch Pulselessness Paresthesias, loss of sensation Paralysis,Deep Vein Thrombophlebitis,Inflammation of lower extremities, pelvic veins with clot formation Usually begins with calf veins Precipitating facto
29、rs Injury to venous endothelium Hypercoagulability Reduced blood flow (venous stasis),Deep Vein Thrombophlebitis,Signs/Symptoms May be asymptomatic Pain, tenderness Fever, chills, malaise Edema, warmth, bluish-red color Pain on ankle dorsiflexion during straight leg lifting (Homans sign) Palpable “c
30、ord” in calf clotted veins,Deep Vein Thrombophlebitis,May progress to pulmonary embolism!,Varicose Veins,Dilated, elongated, tortuous superficial veins usually in lower extremities,Varicose Veins,Causes Congenital weakness/absence of venous valves Congenital weakness of venous walls Diseases of veno
31、us system (Deep thrombophlebitis) Prolonged venostasis (pregnancy, standing),Varicose Veins,Signs/Symptoms May be asymptomatic Feeling of fatigue, heaviness Cramps at night Orthostatic edema Ulcer formation,Varicose Veins,Rupture may cause severe bleeding Control with elevation and direct pressure,A
32、ortic Aneurysm,Localized abnormal dilation of blood vessel, usually an artery Thoracic Dissecting Abdominal,Thoracic Aortic Aneurysm,Usually results from atherosclerosis Weakened aortic wall bows out - lumen distends Most common in males age 50 - 70,Thoracic Aortic Aneurysm,Sign/Symptoms Dyspnea, Co
33、ugh Hoarseness/Loss of voice Substernal/back pain or ache Lower extremity weakness/ paresthesias Variation in pulses, BP between extremities,Dissecting Aortic Aneurysm,Intima tears Column of blood forms false passage, splits tunica media lengthwise Most common in thoracic aorta Most common in blacks
34、, chronic hypertension, Marfans syndrome,Dissecting Aortic Aneurysm,Signs/Symptoms Sudden “ripping” or “tearing” pain anterior chest or between shoulders May extend to shoulders, neck, lower back, and abdomen Rarely radiates to jaw or arms Pallor, diaphoresis, tachycardia, dyspnea,Dissecting Aortic
35、Aneurysm,Signs/Symptoms Normal or elevated upper extremity BP in “shocky” patient CHF if aortic valve is involved Acute MI if coronary ostia involved Rupture into pericardial space or chest cavity with circulatory collapse,Dissecting Aortic Aneurysm,Signs/Symptoms CNS symptoms from involvement of he
36、ad/neck vessel origins Chest pain + neurological deficit = aortic aneurysm,Abdominal Aortic Aneurysm,Also referred to as “AAA” or “Triple A” Usually results from atherosclerosis White males age 50 - 80,Abdominal Aortic Aneurysm,Signs/Symptoms Usually asymptomatic until large enough to be palpable as
37、 pulsing mass Usually tender to palpation Excruciating lower back pain from pressure on lumbar vertebrae May mimic lumbar disk disease or kidney stone Leaking/rupture may produce vascular collapse and shock Often presents with syncopal episode,Abdominal Aortic Aneurysm,Signs/Symptoms May result in u
38、nequal lower extremity pulses or unilateral paresthesia Urge to defecate caused by retroperitoneal leaking of blood Erosion into duodenum with massive GI bleed,Aortic Aneurysm Management,ABCs High concentration O2 NRB Assist ventilations if needed Package patient for transport in MAST, inflate if pa
39、tient becomes hypotensive IVs x 2 with LR enroute Draw labs 12 Lead ECG enroute if time permits,Aortic Aneurysm Management,If patient hypertensive consider reducing BP Nitropaste Beta blocker Consider analgesia Tolerated best if hypertensive Consider transport to facility with vascular surgery capab
40、ility,Pulmonary Embolism,Pathophysiology Pulmonary artery blocked Blood: Does not pass alveoli Does not exchange gases,Causes,Blood clots = most common cause Virchows Triad Venous stasis bed rest, immobility, casts, CHF Thrombophlebitis vessel wall damage Hypercoagulability Birth control pills, espe
41、cially with smoking,Causes,Air Amniotic fluid Fat particles Long bone fracture more quickly splinted, less chance of fat emboli Particulates from substance abuse,Signs/Symptoms,Small Emboli Dyspnea Tachycardia Tachypnea,Signs/Symptoms,Larger Emboli Respiratory difficulty Pleuritic pain Pleural rub C
42、oughing Hemoptysis Localized Wheezing,Signs/Symptoms,Very Large Emboli Respiratory distress Central chest pain Distended neck veins Acute right heart failure Shock Cardiac arrest,Signs/Symptoms,There are NO findings specific to pulmonary embolism,Management,Airway Consider intubation early (if does
43、not cause delay) Breathing 100% O2 NRB mask Consider assisting ventilations (if not intubated) Circulation IV x 2, lg bore, NS, TKO May attempt fluid bolus if hypotensive or shock ECG monitor Rapid transport thrombolysis or pulmonectomy may be useful,Pulmonary Embolism,If the patient is alive when you get to them, that embolus isnt going to kill them, BUT THE NEXT ONE THEY THROW MIGHT!,
