Hypertension for EMS Providers

HYPERTENSIONHYPERTENSIONHYPERTENSIONHYPERTENSION

Paramedic Class 108Paramedic Class 108Paramedic Class 108Paramedic Class 108

IntroductionIntroductionIntroductionIntroduction

• IncidenceIncidence• 50 million Americans50 million Americans• 1 in 5 Americans or 18%1 in 5 Americans or 18%• Undiagnosed 15 million (30% of the 50 Undiagnosed 15 million (30% of the 50

million)million)• 1 in 18 Americans or 5%1 in 18 Americans or 5%

• Morbidity/MortalityMorbidity/Mortality• Gender – Male=49.7. Female=50.3Gender – Male=49.7. Female=50.3• Death Rate (per 100,000) – White Death Rate (per 100,000) – White

Males=14.4, Black Males=49.6, White Males=14.4, Black Males=49.6, White Females=13.7, and Black Females=40.5. Females=13.7, and Black Females=40.5.

Group 1 AssignmentGroup 1 Assignment

• Define Blood PressureDefine Blood Pressure• Define Systolic blood Pressure: NormalDefine Systolic blood Pressure: Normal• Define Diastolic Blood Pressure: NormalDefine Diastolic Blood Pressure: Normal• What are blood pressure perimeters What are blood pressure perimeters

that indicate high pressure.that indicate high pressure.• What are some factors that determine What are some factors that determine

blood pressure. Formulablood pressure. Formula• What factors may affect blood pressure What factors may affect blood pressure

determination. determination.

Blood Pressure Blood Pressure Regulation MechanismsRegulation Mechanisms

• Autonomic Nervous Autonomic Nervous SystemSystem

• Kidneys (Renin-Kidneys (Renin-Angiotensin-Angiotensin-Aldosterone)Aldosterone)

• Endocrine SystemEndocrine System

RENINRENIN

• An enzyme released by the kidney An enzyme released by the kidney that stimulates production of that stimulates production of angiotensin.angiotensin.

• A protein secreted by the kidneys A protein secreted by the kidneys that raises blood pressure back to that raises blood pressure back to normal when it begins to fall. normal when it begins to fall.

ALDOSTERONEALDOSTERONE

• The main electrolyte-regulating The main electrolyte-regulating hormone secreted by the adrenal hormone secreted by the adrenal cortex: primarily controls sodium and cortex: primarily controls sodium and potassium balance. potassium balance.

• Released by the adrenal glands that Released by the adrenal glands that increases blood pressure by increases blood pressure by signaling the kidneys to retain signaling the kidneys to retain sodium, which increases blood sodium, which increases blood volume.volume.

AngiotensinAngiotensin

• A peptide that is produced by a A peptide that is produced by a biochemical reaction caused by the biochemical reaction caused by the enzyme Renin. enzyme Renin.

• Hormone that has two forms: Hormone that has two forms: angiotensin I which is inactive and angiotensin I which is inactive and angiotensin II which is the active form. angiotensin II which is the active form. The latter raises blood pressure by The latter raises blood pressure by causing arteries to constrict and causing arteries to constrict and triggering the release of aldosterone. triggering the release of aldosterone.

Renin-AngiotensinRenin-AngiotensinKNOW THISKNOW THIS

• Renin stimulates formation of angiotensin Renin stimulates formation of angiotensin I:I:• Then converts to angiotensin IIThen converts to angiotensin II

• Angiotensin II is a potent vasoconstrictor Angiotensin II is a potent vasoconstrictor • Stimulates ADH secretionStimulates ADH secretion

• Results in:Results in:• Reabsorption of sodium and waterReabsorption of sodium and water• Elevation in blood pressure Elevation in blood pressure • Activation of renin-angiotensin systemActivation of renin-angiotensin system

ADH ADH

• ADH is a hormone released by ADH is a hormone released by pituitary gland but made pituitary gland but made elsewhere (in the hypothalamus). elsewhere (in the hypothalamus). ADH has an antidiuretic action; it ADH has an antidiuretic action; it suppresses the rate of urine suppresses the rate of urine production. ADH is also known as production. ADH is also known as vasopressin.vasopressin.


• Autonomic Nervous SystemAutonomic Nervous System• Baroreceptors – Measure stretch Baroreceptors – Measure stretch

(heart, great vessels)(heart, great vessels)• Chemoreceptor's – Measure Chemoreceptor's – Measure

hypoxemia, acidosis…pH & PO2 hypoxemia, acidosis…pH & PO2 (carotid, aortic bodies)(carotid, aortic bodies)

• Results in vessel dilation or Results in vessel dilation or constrictionconstriction


• Kidneys (Renin-Angiotensin-Kidneys (Renin-Angiotensin-Aldosterone)Aldosterone)• Decreased BPDecreased BP

• Renin secreted by kidneys. Works on Renin secreted by kidneys. Works on angiotensinogen to produce angiotensin Iangiotensinogen to produce angiotensin I

• Angiotensin I converted to angiotensin II by Angiotensin I converted to angiotensin II by angiotensin converting enzyme (ACE) angiotensin converting enzyme (ACE)

• Vasoconstriction & secretion of aldosterone and Vasoconstriction & secretion of aldosterone and ADH (AKA: Vasopressin)ADH (AKA: Vasopressin)

• Results in water and sodium retention and higher Results in water and sodium retention and higher blood pressure blood pressure


• Kidneys (Renin-Angiotensin-AldosteroneKidneys (Renin-Angiotensin-Aldosterone


• Sketch the Renin – Angiotensin –Sketch the Renin – Angiotensin –Aldosterone mechanism.Aldosterone mechanism.


DefineDefine• HypertrophyHypertrophy• Myocardial hypertrophyMyocardial hypertrophy• Starlings LawStarlings Law• Peripheral Vascular ResistancePeripheral Vascular Resistance

CHF, HTN, & Renal CHF, HTN, & Renal FailureFailure

1.1. Long term untreated HTN leads to Long term untreated HTN leads to hypertrophy (LV).hypertrophy (LV).

2.2. The Starling effect is compromised and the The Starling effect is compromised and the LV is not fully emptied during systole.LV is not fully emptied during systole.

3.3. Decreased Stroke Volume (SV) and Decreased Stroke Volume (SV) and Cardiac Output (CO).Cardiac Output (CO).

4.4. Blood backs up causing CHFBlood backs up causing CHF5.5. Less cardiac output = major organs Less cardiac output = major organs

(vessels, kidneys, brain, eyes) not (vessels, kidneys, brain, eyes) not adequately perfuseadequately perfuse

6.6. Cells are then damaged, begin to fail, and dieCells are then damaged, begin to fail, and die

Hypertension Hypertension DevelopmentDevelopment

Recognized FactorsRecognized Factors• CADCAD• AgeAge• HeredityHeredity• EthnicityEthnicity

• African-Americans, African-Americans, Puerto Ricans, Cubans, Puerto Ricans, Cubans, HispanicsHispanics

• DietDiet• CholesterolCholesterol• FatsFats• SodiumSodium

• WeightWeight• ObesityObesity

• Smokeless Tobacco UsersSmokeless Tobacco Users• Stress/Type A Stress/Type A

PersonalitiesPersonalities

Hypertension EtiologyHypertension EtiologyPrimary HypertensionPrimary Hypertension

• No specific identifying causeNo specific identifying cause• Arteriole wall vasoconstriction, wall damageArteriole wall vasoconstriction, wall damage• Many risk factorsMany risk factors• Develops over yearsDevelops over years• May or may not be symptomaticMay or may not be symptomatic• Treatment aimed at lowering BP through diet Treatment aimed at lowering BP through diet

and medicationsand medications• Patient Home Medications - CardiacPatient Home Medications - Cardiac

• No specific identifying causeNo specific identifying cause• Arteriole wall vasoconstriction, wall damageArteriole wall vasoconstriction, wall damage• Many risk factorsMany risk factors• Develops over yearsDevelops over years• May or may not be symptomaticMay or may not be symptomatic• Treatment aimed at lowering BP through diet Treatment aimed at lowering BP through diet

and medicationsand medications• Patient Home Medications - CardiacPatient Home Medications - Cardiac

Hypertension EtiologyHypertension EtiologyPrimary HypertensionPrimary Hypertension

• Patient Home Patient Home Medications – Medications – CardiacCardiac• Beta BlockersBeta Blockers• Calcium Channel Calcium Channel

BlockersBlockers• Adrenergic InhibitorsAdrenergic Inhibitors• ACE InhibitorsACE Inhibitors• ARBSARBS• Diuretics Diuretics

Group 4 AssignmentGroup 4 AssignmentHome MedicationsHome Medications

Describe the therapeutic actions for Describe the therapeutic actions for each class & identify several each class & identify several medications that are used.medications that are used.

• Beta BlockersBeta Blockers• Calcium Channel blockersCalcium Channel blockers• ACE Inhibitors ACE?ACE Inhibitors ACE?• ARBS –ARBB?ARBS –ARBB?• DiureticsDiuretics

Hypertension EtiologyHypertension EtiologySecondary HypertensionSecondary Hypertension

• Often has an identifying causeOften has an identifying cause• 10% of hypertension cases10% of hypertension cases• Abrupt onset Abrupt onset • Commonly renal in originCommonly renal in origin

• Renal artery stenosisRenal artery stenosis• Polycystic diseasePolycystic disease• Fibro-muscular disease of renal arteryFibro-muscular disease of renal artery

• Adrenal tumorsAdrenal tumors

• Often has an identifying causeOften has an identifying cause• 10% of hypertension cases10% of hypertension cases• Abrupt onset Abrupt onset • Commonly renal in originCommonly renal in origin

• Renal artery stenosisRenal artery stenosis• Polycystic diseasePolycystic disease• Fibro-muscular disease of renal arteryFibro-muscular disease of renal artery

• Adrenal tumorsAdrenal tumors

Anatomical Damage from Anatomical Damage from HypertensionHypertension

• VesselsVessels• KidneyKidney• BrainBrain• HeartHeart


• VesselsVessels• Large vessels – Sclerosis Large vessels – Sclerosis

(hardened)(hardened)• Narrowed lumen – tunica media Narrowed lumen – tunica media

hypertrophy, tunica intima hypertrophy, tunica intima with endothelium damage with endothelium damage (allows vascular content (allows vascular content leakage)leakage)

• Lose of elasticity Lose of elasticity • Decreased blood flowDecreased blood flow• Occlusion, tear, rupture Occlusion, tear, rupture

(aneurysm)(aneurysm)• Increased PVRIncreased PVR• Aorta – Weakens and leads to Aorta – Weakens and leads to

aneurysmsaneurysms• Small vesselsSmall vessels

• Damage to intima layerDamage to intima layer• Scar tissueScar tissue• Fibrin strands/clot formationFibrin strands/clot formation• ObstructionObstruction


• KidneyKidney• Poor perfusion leads to Poor perfusion leads to

organ damageorgan damage• Decreased function…Decreased function…

failurefailure• In many cases, leads to In many cases, leads to

renal dialysisrenal dialysis


• BrainBrain• Stroke/CVA – Cerebral Vascular Stroke/CVA – Cerebral Vascular

AccidentAccident• TIA – Trans Ischemic AttackTIA – Trans Ischemic Attack


• HeartHeart• As described earlierAs described earlier• AMIAMI

• Vessel obstruction from poor Vessel obstruction from poor blood flow (coronaries)blood flow (coronaries)

• HypertrophyHypertrophy• Outgrows blood supplyOutgrows blood supply• Smaller chamber sizeSmaller chamber size• Decreased CO – Incomplete LV Decreased CO – Incomplete LV

emptyingemptying• CHF – Congestive Heart Failure CHF – Congestive Heart Failure

(result of increased PVR) (result of increased PVR) • Poor perfusion of other organs, Poor perfusion of other organs,

related to COrelated to CO

Pre-hospital Hypertensive Pre-hospital Hypertensive CrisisCrisis

• Pathophysiology can cause intercerebral or Pathophysiology can cause intercerebral or subarchnoid bleeding and cerebral infarctssubarchnoid bleeding and cerebral infarcts

• Cerebral edemaCerebral edema• BP generally greater than 100 mmHg BP generally greater than 100 mmHg

diastolicdiastolic• Other key organs can be damaged as wellOther key organs can be damaged as well• Common cause is sudden discontinuation Common cause is sudden discontinuation

of HTN medicationsof HTN medications• Pregnancy Induced Hypertension is a Pregnancy Induced Hypertension is a

common cause (5% of pregnancies) common cause (5% of pregnancies)


• Signs/Symptoms – Signs/Symptoms – Marked BP ElevationMarked BP Elevation• HeadacheHeadache• NauseaNausea• VomitingVomiting• ConfusionConfusion• RestlessRestless• SeizureSeizure• StrokeStroke• ComaComa

• Frequent LOC checksFrequent LOC checks

• AMIAMI• ArrhythmiasArrhythmias

• EKG EKG monitoringmonitoring

• NosebleedsNosebleeds• Airway issuesAirway issues


ManagementManagement• Rapid lowering of BP can be dangerousRapid lowering of BP can be dangerous

• Slow lowering (2-6 hours) of BP is preferredSlow lowering (2-6 hours) of BP is preferred• Ischemia and infarct is possibleIschemia and infarct is possible• Nitroprusside Nitroprusside • Nitroglycerine is not preferred in the EMS environmentNitroglycerine is not preferred in the EMS environment

• Pre-hospital therapies:Pre-hospital therapies:• Airway control, as neededAirway control, as needed• Calm, reassure patientCalm, reassure patient• Oxygenation & VentilationOxygenation & Ventilation• IV – TKOIV – TKO• EKG MonitoringEKG Monitoring• LOC reassessmentLOC reassessment• Vital signsVital signs

Long Term Treatment of Long Term Treatment of HypertensionHypertension

• Slight decrease (5%) in BP will decrease Slight decrease (5%) in BP will decrease the risk of stroke by 35-40%the risk of stroke by 35-40%

• Adequate treatment of high blood Adequate treatment of high blood pressure will decrease:pressure will decrease:• Heart failure 52% (Higher risk for CHF)Heart failure 52% (Higher risk for CHF)

• Often develops into CHF 91%Often develops into CHF 91%

• Stroke 38%Stroke 38%• LV Hypertrophy 35%LV Hypertrophy 35%• Cardiovascular Mortality 21% Cardiovascular Mortality 21%

• Slight decrease (5%) in BP will decrease Slight decrease (5%) in BP will decrease the risk of stroke by 35-40%the risk of stroke by 35-40%

• Adequate treatment of high blood Adequate treatment of high blood pressure will decrease:pressure will decrease:• Heart failure 52% (Higher risk for CHF)Heart failure 52% (Higher risk for CHF)

• Often develops into CHF 91%Often develops into CHF 91%

• Stroke 38%Stroke 38%• LV Hypertrophy 35%LV Hypertrophy 35%• Cardiovascular Mortality 21% Cardiovascular Mortality 21%

Hypertension Prevention Hypertension Prevention & EMS Role& EMS Role

• EMS has a role in educating the publicEMS has a role in educating the public• Prevention ProgramsPrevention Programs• On-scene EducationOn-scene Education


• What to educate:What to educate:• Lifestyle changes @ early ageLifestyle changes @ early age• Good dietGood diet

• Reduce cholesterol, lipids, and triglyceride levelsReduce cholesterol, lipids, and triglyceride levels• ExerciseExercise• Avoid tobaccoAvoid tobacco• Take prescribed medicationsTake prescribed medications

• What to educate:What to educate:• Lifestyle changes @ early ageLifestyle changes @ early age• Good dietGood diet

• Reduce cholesterol, lipids, and triglyceride levelsReduce cholesterol, lipids, and triglyceride levels• ExerciseExercise• Avoid tobaccoAvoid tobacco• Take prescribed medicationsTake prescribed medications


• EMS ActivitiesEMS Activities• FD station BP checks, educate as FD station BP checks, educate as

neededneeded• Organized healthcare screenings, Organized healthcare screenings,

educate as needededucate as needed• On-scene treatment and educationOn-scene treatment and education


Scenario:Scenario:58 yo female c/o HA dizzy. Ran out 58 yo female c/o HA dizzy. Ran out

of Meds . Propranolol, captopril, of Meds . Propranolol, captopril, valsartan, furosmide, nitroglycerinvalsartan, furosmide, nitroglycerin

Are the medications cardiac related?Are the medications cardiac related?VS. 198/110 92 irreg. 16 non laboredVS. 198/110 92 irreg. 16 non laboredPatient History?Patient History?Your Treatment?Your Treatment?

Scenario:Scenario:58 yo female c/o HA dizzy. Ran out 58 yo female c/o HA dizzy. Ran out

of Meds . Propranolol, captopril, of Meds . Propranolol, captopril, valsartan, furosmide, nitroglycerinvalsartan, furosmide, nitroglycerin

Are the medications cardiac related?Are the medications cardiac related?VS. 198/110 92 irreg. 16 non laboredVS. 198/110 92 irreg. 16 non laboredPatient History?Patient History?Your Treatment?Your Treatment?

REVIEWREVIEWREVIEWREVIEW

HypertensionHypertension

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SymptomsSymptoms

HypertensionHypertension

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SymptomsSymptoms

QUESTIONS?QUESTIONS?

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Hypertension for EMS Providers