My buddy, Mike Weinstock, writes an amazing series of Emergency Medicine books called Bouncebacks. I brought Mike back to talk about a chapter from the book on a 55-year-old male who presented with hypertension. Needless to say, he bounced back. This episode has Mike walk us through the case and we discuss the various points it raises.
Michael Weinstock
Mike Weinstock is an emergency medicine physician, Director of research Adena Health System, Prof of EM adjunct at Ohio State, exec editor UC MAX podcast, lead clinical editor JUCM
Other Episodes with Mike
- EMCrit 303 – A Bounceback Case with Mike Weinstock
- EMCrit Wee – The Mock Trial Verdict and a Discussion with Mike Weinstock
The Book
The Chapter from Mike's Book: Bouncebacks! Critical Care
ACEP Clinical Policy on Asymptomatic Hypertension
Additional New Information
More on EMCrit
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Why don’t you use Clevidipine?
not generic, most hospitals restrict it and discourage use unless necessary
As a prehospital nurse, I often wonder how you’d want us to treat these rse cases in a way that would get you the best start on treatment. I think we’ve all seen those status patients who don’t respond even to repeat midazolam. My state doesn’t allow the use of Keppra or pheno- drugs for ALS, so on report I would recommend ketamine, and hopefully get a sympathetic doc in a box to let me drop the tube. Is this an approach you would endorse, or might this interfere with your workflow?
Another great episode with Mike, so many pearls. repeat blood pressure would be mandatory and hard to believe the pt left without one on the initial visit. while not possible in many shops i will call/have someone call the pt’s clinic and get them a follow up appointment in the next 48 hrs or whatever timeframe is needed for the disease and when able ask the pcp if there are labs/meds/etc that they want done prior to them seeing the pt. the other thing i’ve been doing more of is having the pt’s nurse in the room documenting in their… Read more »
great comments, brother
Brian Levy, MD, FACEP I think that one of the morals of this story is, with due respect to Phillip Shayne and others who have vociferously advocated for us not to treat “asymptomatic hypertension,” that we are asking for a decade or so of misery and litigation by failing to treat pressures > 180 or so, anyway (pick your number; maybe even 160). Rosen’s and the ACEP policy is not currently serving us well. Like it or not, we live in a time where physicians will be held accountable for poor decisions on the part of patients, especially if we… Read more »
Thanks for the great episode.
—SPOILERS—
Excuse me if I am missing an obvious point, but how are the first presentation with high BP and the seizures next day(eventually diagnosed as PRES) linked? Whole medicolegal aspect aside, is there any causation/correlation? Thanks.
would be tough to imagine they are unrelated. PRES is almost always temporally related to uncontrolled hypertension. As to whether it is the cause, result, or a cyclical component can be debated, but it would be hard to say that the blood pressure the day before is an innocent bystander
So why not start bp med in asymptomatic hypertensive pt in the ed. How is this different from the pcp starting pt on treatment or as is the case in many, there is no pcp. Excellent episode, but this point was kind of just left hanging out there. What would be the downside(s) of doing so. And I’ll take my answer off the air.
fantastic episode guys wondering what your take is on patients presenting with isolated headache (not thunderclap, no red flag features) and hypertension. assuming no ICH, what’s your take on headache alone being a SYMPTOM of hypertension (without visual changes, neurologic complaints etc.)? i’m often under the impression the underlying headache is causing the hypertension, not the other way around– i’ve never seen a case of PRES/htn encephalopathy presenting with initial headache and then deteriorating. thoughts? e.g. 75yo F presents with first time moderate/non-thunderclap headache, no visual changes, neuro exam normal, BP 180/95, BP 140/90 6mo ago documented. CT neg. your… Read more »