Questions on BP trend

[nikolaite]

Took me forever to transcribe this on my iPhone...LOL. Anybody have any insight on what is going on with this pt’s bp? If you want further details I can try to pull them, just have to be careful of pt’s PHI. Thanks for your time, everyone!

No supplemental O2 except b/n Day 1, 2000 and 2200. EKG: normal sinus rhythm throughout, with a couple PVCs.

Order: hydrALAZINE (Apresoline) 20 mg/mL injection 10 mg

PRN reasons: systolic blood pressure greater than 170 mmHg

Frequency: q4h PRN

Day 1, 1318 bp 214/119 hr 85, rr 22, spo2 95
Day 1, 1603, bp 164/95, hr 83, rr 12, spo2 95
Day 1, 1619, bp 149/85, hr 92, rr 13, spo2 x
Day 1, 1635, bp 167/110, hr 88, rr 22, spo2 x
Day 1, 1639, bp 167/85, hr 93, rr 27, spo2 95
Day 1, 1648, bp 174/94, hr 95, rr 21, spo2 92
Day 1, 1738, bp 186/92, hr 95, rr 20, spo2 93
Day 1, 1800, bp 177/95, hr 94, rr 22, spo2 96
Day 1, 1801, bp 177/95, hr 97, rr 21, spo2 x
Day 1, 1817, bp 157/96, hr 94, rr 24, spo2 90
Day 1, 1947, bp 177/133, hr 99, rr 18, spo2 95
Day 1, 1948, bp 189/90, hr 98, rr 18, spo2 95

First dose: Day 1, 2014, Given 10 mg intravenous hydrALAZINE

Day 2, 0023, bp 156/77, hr 76, rr 18, spo2 96
Day 2, 0349, bp 166/94, hr 94, rr 18, spo2 97
Day 2, 0815, bp 211/109, hr 89, rr 18, spo2 98

Second dose: Day 2, 0828, Given 10 mg intravenous hydrALAZINE

Day 2, 1006, bp 206/103
Day 2, 1242, bp 189/122, hr 96, rr 18, spo2 99
Day 2, 1253, bp 191/103, hr 97, rr x, spo2 98

No bps recorded for rest of inpatient course. No other hydrALAZINE admin records.

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[Crayola227]

Took me forever to transcribe this on my iPhone...LOL. Anybody have any insight on what is going on with this pt’s bp? If you want further details I can try to pull them, just have to be careful of pt’s PHI. Thanks for your time, everyone!

No supplemental O2 except b/n Day 1, 2000 and 2200. EKG: normal sinus rhythm throughout, with a couple PVCs.

Order: hydrALAZINE (Apresoline) 20 mg/mL injection 10 mg

PRN reasons: systolic blood pressure greater than 170 mmHg

Frequency: q4h PRN

Day 1, 1318 bp 214/119 hr 85, rr 22, spo2 95
Day 1, 1603, bp 164/95, hr 83, rr 12, spo2 95
Day 1, 1619, bp 149/85, hr 92, rr 13, spo2 x
Day 1, 1635, bp 167/110, hr 88, rr 22, spo2 x
Day 1, 1639, bp 167/85, hr 93, rr 27, spo2 95
Day 1, 1648, bp 174/94, hr 95, rr 21, spo2 92
Day 1, 1738, bp 186/92, hr 95, rr 20, spo2 93
Day 1, 1800, bp 177/95, hr 94, rr 22, spo2 96
Day 1, 1801, bp 177/95, hr 97, rr 21, spo2 x
Day 1, 1817, bp 157/96, hr 94, rr 24, spo2 90
Day 1, 1947, bp 177/133, hr 99, rr 18, spo2 95
Day 1, 1948, bp 189/90, hr 98, rr 18, spo2 95

First dose: Day 1, 2014, Given 10 mg intravenous hydrALAZINE

Day 2, 0023, bp 156/77, hr 76, rr 18, spo2 96
Day 2, 0349, bp 166/94, hr 94, rr 18, spo2 97
Day 2, 0815, bp 211/109, hr 89, rr 18, spo2 98

Second dose: Day 2, 0828, Given 10 mg intravenous hydrALAZINE

Day 2, 1006, bp 206/103
Day 2, 1242, bp 189/122, hr 96, rr 18, spo2 99
Day 2, 1253, bp 191/103, hr 97, rr x, spo2 98

No bps recorded for rest of inpatient course. No other hydrALAZINE admin records.

I mean, my first thought it why are they so tachypneic, and then why are they on NC? But then my next thought is that this is a totally ridic case because you haven't even told us why this person is hypertensive or what's wrong with them and why are they being treated with hydrALAZINE.

Lastly, most patient records are considered deidentified without name, DOB, age, location, and don't have super rare illnesses or a particularly unique course.

You also haven't really asked a question.

Let's say I just assume they have benign essential hypertension which for whatever reason is being managed with something short acting like hydrALAZINE. I don't see anything unusual in the trend you posted for that. What other meds are they on? Because it isn't just the HTN that raises the eyebrow, it makes a big difference if this is this guy's BP and he's already on like 3 agents that are maxed out.

 

[nikolaite]

I hear ya. Thanks for your response. I apparently zonked out from two finger typing fatigue and forgot to add my questions. The reason I mentioned PHI is because I might need extra time in replying if someone asks for additional info to make sure I’m not copying & pasting identifiers.

Pt had no history of hypertension, but was brought into hospital by EMS with suspected stroke at 1330. Pt demonstrated alertness w/global aphasia, ataxia, inability to follow commands, r face droop, rue neglect, etc. CT done at about 1530. Pt became unconscious/unresponsive except to noxious stimulus or sternal rub at about 1600. Handwritten notes diverge from tabular trends a bit putting spo2 trends b/n 80 and 90 from 1600 to 1800. Pt regained degree of consciousness at about 1940. CTA done at 2050. Was diagnosed with LVO and stroke around 2100. No idea about the reasoning behind hydrALAZINE in particular; none is recorded.

Pt medications in history, only aspirin prn for pain, afrin prn for congestion, caffeine 100-200 mg q4h, and some supplements like ascorbic acid daily. Pt family reported pt took 100 mg caffeine that AM, but nothing else in past 12 hours.

No alcohol or substance abuse in hx. No tox screen run.

MAR from ER had only one albuterol nebs 2.5 mg/3 mL, noted pt tolerated treatment for 30 sec b/n 1620 and 1630. 10 mg lorazepam IM admin b/n 1400 and 1439. 2 mg lorazepam IVP at 1715. 2 mg lorazepam IVP at 1803. (NB: I’ve been seeing a lot of this apparently heavy reliance on lorazepam in the ER; my colleagues assure me this is normal. Looks freaky to me, though.) No tPA.

So, my questions:

What is the usual reason behind lengthy gaps in bp and other vitals reads?

What is the usual reason why some are taken within 1-2 mins of the previous and then recorded?

Since there is some recorded divergence b/n handwritten notes and tabular trends records, are the measurements to be held as suspect as inaccurate measurements?
What sort of underlying issue could account for the tachypneia? Is this the lorazepam? I thought that would reduce rr.

Why with the tachypnea would there be no end-tidal cap?...and especially why after the Ativan doses?

Why would a provider choose hydrALAZINE over other options? Seems like it’s not ideal in suspected stroke cases for the risk of increasing intracranial pressure...though I read a study from the 70’s which seems to suggest the increase in intracranial pressure with reduction in systemic bp has a positive effect.

Since no tPA, why treat the bp at all?

Why would there be no attempt to control bp prior to 2014 if it needed to be controlled?

And why was the hydrALAZINE having no apparent effect after the second dose?

Thanks again!

 

[nikolaite]

Also, NC was recorded as due to verbal report from ER of lengthy hypoxia. Mid-level ordered 2L/min at 1950, in service at 2000. Pt removed NC at approx 2100, service discontinued at 2200.

 

[Redpancreas]

IV Hydralazine is a short acting vasodilator with unpredictable pharmacodynamics that shouldn’t be used as a PRN BP medication. That’s what’s going on

 

[Redpancreas]

I hear ya. Thanks for your response. I apparently zonked out from two finger typing fatigue and forgot to add my questions. The reason I mentioned PHI is because I might need extra time in replying if someone asks for additional info to make sure I’m not copying & pasting identifiers.

Pt had no history of hypertension, but was brought into hospital by EMS with suspected stroke at 1330. Pt demonstrated alertness w/global aphasia, ataxia, inability to follow commands, r face droop, rue neglect, etc. CT done at about 1530. Pt became unconscious/unresponsive except to noxious stimulus or sternal rub at about 1600. Handwritten notes diverge from tabular trends a bit putting spo2 trends b/n 80 and 90 from 1600 to 1800. Pt regained degree of consciousness at about 1940. CTA done at 2050. Was diagnosed with LVO and stroke around 2100. No idea about the reasoning behind hydrALAZINE in particular; none is recorded.

Pt medications in history, only aspirin prn for pain, afrin prn for congestion, caffeine 100-200 mg q4h, and some supplements like ascorbic acid daily. Pt family reported pt took 100 mg caffeine that AM, but nothing else in past 12 hours.

No alcohol or substance abuse in hx. No tox screen run.

MAR from ER had only one albuterol nebs 2.5 mg/3 mL, noted pt tolerated treatment for 30 sec b/n 1620 and 1630. 10 mg lorazepam IM admin b/n 1400 and 1439. 2 mg lorazepam IVP at 1715. 2 mg lorazepam IVP at 1803. (NB: I’ve been seeing a lot of this apparently heavy reliance on lorazepam in the ER; my colleagues assure me this is normal. Looks freaky to me, though.) No tPA.

So, my questions:

What is the usual reason behind lengthy gaps in bp and other vitals reads?

What is the usual reason why some are taken within 1-2 mins of the previous and then recorded?

Since there is some recorded divergence b/n handwritten notes and tabular trends records, are the measurements to be held as suspect as inaccurate measurements?
What sort of underlying issue could account for the tachypneia? Is this the lorazepam? I thought that would reduce rr.

Why with the tachypnea would there be no end-tidal cap?...and especially why after the Ativan doses?

Why would a provider choose hydrALAZINE over other options? Seems like it’s not ideal in suspected stroke cases for the risk of increasing intracranial pressure...though I read a study from the 70’s which seems to suggest the increase in intracranial pressure with reduction in systemic bp has a positive effect.

Since no tPA, why treat the bp at all?

Why would there be no attempt to control bp prior to 2014 if it needed to be controlled?

And why was the hydrALAZINE having no apparent effect after the second dose?

Thanks again!

If the patient had a stroke, I’m sure they had a history of HTN. I don’t meant to be condescending but what are the reasons for your question? It seems like you’re either a medical student who hasn’t started clinicals or someone outside of medicine who doesn’t seem to know that’s going on. If it is the former, focus on the basics and try not to hyperanalyze on these trends.

 

[gyngyn]

Closing misaligned thread.