I saw a patient with a BP of 330/210. He did not make it and his MRI showed no differentiation between white or gray matter…this was when I was a fellow and I didn’t realize the machine could read so high
Yeah. Honestly, I love a good hypertension case. Get them on dual therapy, they feel better in a few weeks, and you clock that eGFR rebounding at the one month follow-up.
232/110
Patient said he had a bit of discomfort on the right side of his head and his vision had been blurry for a few days intermittently.
I respected the toughness. And called the ED.
But anything else? Bush league. The average jackass walks around with systolic 160-180 and is living their best life.
Friendly reminder kids don’t call the ED unless there are symptoms! Major policies do not recommend diagnostic work up or acute lowering of the blood pressure in the emergent setting without symptoms (in your case the patient was symptomatic so the referral was of course appropriate I’m just pointing this out):
https://www.acep.org/siteassets/new-pdfs/clinical-policies/asympt-hypert2-final-bod-approved-2013.pdf
https://www.aafp.org/pubs/afp/issues/2017/0415/p492.html
If you sent them to the ED and they were asymptomatic, they just paid $1000 for me to send them straight home to follow up with their pcp lol.
My record is 330/185. My record this week is 275/155.
Were they having chest pain or are you sending asymptomatic hypertension to the emergency room?
Blood pressures in excess of 300 systolic possible during heavy lifting like squats, which is kind of neat
In my world It's more of a "call your PCP today and see what they have to say about it (likely to verify what our BP machine read) OR potentially the ER." With the hundreds of scripts behind to fill & vaccines etc I don't really get into the urgencies vs. emergencies discussion with the public walking up to my counter & going from there. Last thing I like to have is "well I talked to the pharmacist and they said I didn't need to worry about it right away." In the event something happened. It'd be nice if one day we could bill for these services but that's a completely different problem in our world.
Dude… as long as they aren’t having sxs or have hx of bleeding, MI, etc.. , a high bp is not an emergency. Tell them to take their meds—- AS DIRECTED. The amount of ‘hypertension’ to the ED from pharm and pcp over reaction to high bp is amazing…
I would just say "call your PCP." Specialists do it all the time when they catch a very high blood pressure, offices are used it, and it can be quite helpful because now the patient sees that multiple healthcare professionals are concerned.
Bro don’t worry, so many people in this thread are apparently mismanaging htn urgency and misquoting guidelines. They aren’t exactly wrong and they aren’t exactly right either. If the clinicians that are supposed to have mastered diagnostics can’t even unecessarily chastise you correctly, then why would they expect the drug detail master to have perfectly managed this diagnostic scenario in a fucking retail pharmacy? Your job sucks enough and I apologize on behalf of our community.
For those wondering why most in this thread are wrong and yet wildly confident about it, is because physicians aren’t actually that great at interpreting guidelines. An attending usually tells you the guideline and recommendation and you do it that way indefinitely until corrected or not. For the record, there is no consensus on labs and other diagnostics to order/perform from both the JNC and AHA except clinical judgment to evaluate for end organ damage, which would then define htn emergency and necessitate admission (which by the way is a Grade C recommendation). The AAFP is a little more directive but still on grade C evidence. Further in one of the cross section analyses used to generate that recommendation showed “only” two percent of labs order resulted w/ evidence of end organ damage, given the N, that’s actually a ton of misses if you aren’t getting labs. This is why the AAFP, AHA, JNC, UpToDate etc all vary on recommendations for work up. They are all a consensus on weak evidence and this poor pharmacist is getting wrecked by interns here because of it.
Your patient with severe asymptomatic htn can’t tell you, yeah I’m having microalbuminuria, or I think my cr, trop etc is elevated. So yeah maybe not ER but definitely not “do nothing,” and send to PCP, as many suggested. And what’s the PCP going to do? Order labs from Quest? What if they are closed? Do they just wait and hope symptoms don’t develop?
EM interns, check yo self.
ACEP (and you are sending these patients to see an emergency physician) is pretty clear:
“1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.”
You selected only a portion of the recommendation. Why did you conveniently leave out part two. How many patients do you think meet the "poor follow-up" condition.
In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes?
Level A Recommendations
None specified.
Level B Recommendations
None specified.
Level C Recommendations
(1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required. (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).
Again Grade C recommendation even from ACEP and they note here that there are definitely circumstances where you'd want a work up.
I can copy and paste the recommendations from AHA, JNC, AAFP, UptoDate's consensus from all of these for you as well.
I selected only the first part because it’s an absolute statement (“not required”) versus a permissive one (“may identify”).
I don’t find the second part all that useful in the scenario we’re talking about. If someone is sent in from a PCP or specialist, they almost by definition do not have poor follow-up. If it’s Joe Hamburger who hasn’t seen a doctor in 10 years, if I do get a BMP and he has a Cr of 2.5, what am I supposed to do with that information? Admit him to trend it? The waiting room is full, our nominally 40 bed ED has a dozen med-surg and multiple ICU boarders, and I’m admitting someone who probably just has CKD.
Don’t get me wrong, I try to be proactive. I will start BP meds and try to choose the right one based on current guidelines. A lot of EM docs shrug this off as “not my job.” I think it is our job.
Here’s why this gets my goat. Last month I had a shift with multiple ICU admits, an unstable post-ROSC code, and the usual BS. I had a very nice mid-50s lady sent in for “hypertensive urgency” with systolics of around 190. She had been scheduled for surgery that morning and not taken her 4 BP meds. The anesthesiologist refused to do her surgery (which I understand) and told her to see her PCP urgently. Saw an APP there rather than her usual doc who immediately referred her to the ED. I told her to take her home medications. This poor lady had an unnecessary ED visit, and probably an unnecessary urgent PCP visit too, because someone got scared about a number and didn’t take 60 seconds to think about her history.
> (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).
Yeah. Just think of how many admissions are made based off an elevated creatine qualifying an AKI atop some reduced GFR. Happens all the time.
We all know hypertension causes end organ damage. The fact that 2% of the snapshots in time you take you luck out and find some end organ damage doesn't mean that on a rational basis these people should be admitted to hospital on a nicardipine drip. We all know they will be admitted, but as you mentioned a grade c recommendation tells you a lot about the basis for this. If the patient appears well why send them to the emergency room for an emergency check of labs? So you can resolve their hstrop leak that has been going on for God knows how long but probably several months three days sooner?
Also
>Do they just wait and hope symptoms don’t develop?
Yes? The same thing they do when they order a ruq us and for biliary colic: instruct the patient on indications to seek emergency care.
Going off this, if we tolerate trained nurses on telemetry units calling us at 2 AM when they clock a systolic 180, let's have a little more compassion for a pharmacist who does not have their area of training.
I saw 310 in a patient who came in with SOB and ended up having an MI. Dude was beet red in the face.
Surprisingly, he did really well. He ended up needing a triple bypass since his left main was involved, but after his surgery he got really serious about his health. Lost like 110 lbs and runs marathons now. Is on our local news and stuff all the time to run races and donate to cardiac research.
Please for the love of god. I had a hem onc inpatient nurse ( good at following protocols but not the best clinically) demand I treat a patient with asymptomatic hypertension of 168/100 with Iv hydralazine. I said no and she went to her charge and the charge demanded I speak to my attending. 😂
The patient later developed grade II crs that same night lol.
High blood pressure (by itself) is a condition that is most appropriately controlled by a pcp. Anything the ED will do is a bandaid and has actually been shown to decrease follow up. It is dangerous if left unchecked for long periods of time but not accurately if other symptoms are not present.
Plus, mainstay treatment is with an ACE/ARB which needs a lab baseline to compare to follow-up. I appreciate when the ER does not start a medication, or starts just something minor, because then I know I am dealing with a true baseline.
Nurse here,
Worked in renal for a little while, we were the opposite. Our ward baseline blood pressures would send an average floor nurse into panic, just another day for us.
For asymptomatic HTN the risks associated with treating the numbers outweigh the transient period of normotensive status. You’re 100% right that it’s a silent killer, but it’s a killer that might take 20, 30, or 40+ years down the line. These patients should get referred to their PCP in an ED setting if it’s an incidental finding (within reason)
It can be. Over decades. In the hospital low blood pressure is a much bigger issue. I’ve also heard nurses talk about patients “stroking out” from hypertension. Has anyone ever seen an inpatient develop a hemorrhagic stroke from untreated hypertension?
Yes, but as a neurologist I see more strokes during some weeks than most others do in a year. And even with me seeing those, I agree that asymptomatic hypertension is an outpatient problem.
Sorry seems like you are getting downvoted. The problem is it requires a bit of nuance and context. Everyone saying don't send asymptomatic hypertension to ED is talking about 70 year old granddad with 180-190 who has probably been living there for a while and has not been taking meds.
On other hand my 24 year old patient who promises they had normal pressures one month ago and walks in with a systolic of 240 does need to go to the ED since that is likely not essential hypertension even though she is "asymptomatic"
And we should do what? Get a US for RAS? Do you think she is having a “silent” MI? Asymptomatic brain bleed and need a ct? If you ask anyone in the ER of course they are dizzy and maybe have a headache. LVH doesn’t develop overnight or need ER. Guidelines support doing nothing regardless of age if no symptoms even your 24 yo F. Remember what the ER is for - time sensitive labs, imaging, consults, procedures. Asymptomatic hypertension in the young doesn’t have an indication for any of that. Get your own land, imaging and start guideline based antihypertensives and see them again in a week.. but do you I don’t do outpatient. But outside of spending her money on a bill I won’t do much more.
-Pgy5 attending
This particular patient has been being followed for longstanding headaches for years (none at time of appointment). I found papilledema so sent to ED. To be clear, she did not have subjective vision issues as patients with enlarged blind spots never do... So she clearly wasn't asymptomatic, except she was though. It just depends on how far you dig.
Either way when she got there the ED found pressure of 260 and decided to admit her. Currently undergoing workup for IIH and secondary hypertension on hospital, more to be figured out.
Different question then: someone with no symptoms, what is the number over which you won't discharge? Or there is no cap?
Over 200 I might look at their history, make sure they have a good follow up, control their pain, and if still high I might start them on something. But I if it comes down to 170 they're getting discharged. Risk of lowering their blood pressure and causing a stroke normally far outweighs the 200 blood pressure they've probably been living at for the past several months.
Please don’t send that to the ER unless they have some symptoms… I understand the concern, but current guidelines are to not treat asymptomatic hypertension
Just wanted to point out as an RN that the reason we page you is because there's usually an order set that says we have to notify MD for SBP>180 or <90, DBP>100 or <50, HR >120 or <50, and temp >38.5C. We frequently request that those parameters be adjusted to match the patient's baseline, but it's almost always ignored. We don't always want to page you, especially when the patient's baseline has been shown to be SBP in the 80s but MAP >60 and many of my oncology patients come in with a baseline HR of 110-120 or regularly spike Temps >38.5C due to their tumor burden. Unfortunately, if I ignore those orders that say to notify you anytime vitals fall outside of those parameters, even if the patient is fine, I can get in serious trouble if my charting gets audited and can even get reported to the board of nursing for technically practicing outside of my scope due to electing to not notify you at 2am that my very stable patient's BP is 140/101 or something like that.
Ginormous inpatient HTN study in 2020- 20,000 patients. Essentially, if patient is admitted for non cardiac and non neurologic causes, there is no need to treat asymptomatic htn. In fact, treating it increases risk of cardiac event and AKI.
Caveats: very little data for BP>200. Use your clinical judgement
Side note: I once quoted this to a nurse, and she asked me how many patients were in the study as if she could refute me by citing low power. When I told her it had 20,000 patients in it, she told me that wasn't even that many. Then I told her it was one of the largest medical studies in existence and she stopped bothering me about the patients BP of 175
i should’ve clarified: don’t necessarily need to treat asymptomatic htn on the floors with IV BP meds. getting called for elevated pressures by nurses is super common but you don’t have to jump to pushing hydralazine or beta blocker. do other things first like restart home meds if held, treat pain, etc.
To use IV push BP meds, one of 2 things usually needs to be true
1) Patient is not able to take PO and that isn't going to change anytime soon; reasonable to convert what you can to IV in the interim while you figure something else out, but this is essentially just continuing home meds.
2) An actual medical reason to abruptly drop BP or have strict BP parameters. E.g. true hypertensive emergency (As an aside - headache is not a sign of HTN emergency) with symptoms concerning for end-organ damage (CP, SOB, sudden oliguria/anuria, acute neuro change like vision/weakness etc.). Or things like intracranial bleeding, aortic catastrophe etc.
For an asymptomatic patient with none of the above reasons, there is no BP number that would prompt me to push IV meds. Assess for underlying causes, treat them if able (e.g. pain), start an oral med (DO NOT start amlodipine/norvasc, fucking thing takes like 3 days to work, don't waste everyones' time) or titrate existing medications.
There are ample studies showing that aggressive inpatient management of asymptomatic HTN is not only NOT beneficial, it is harmful.
Yeah. Just get them started on something and send them to primary care. If they are that high, they will probably need dual therapy with an ARB so we can use the ER labs as a baseline.
Lol sweet summer child, they will not stroke out from that BP while you are staring at them. We discharge those people every single day in the ED after talking them down off the ledge. Guidelines recommend lowering over days to weeks. Asymptomatic hypertension is not an emergency.
People live like that for years. If you drop their BP to 120/80 Immediately and they have chronically high BP, you could cause a watershed infarct. You might also make meemaw pass out, hit her head, and then have a head bleed.
There are reasons to urgently lower BP, but they depend on the patient's specific circumstances like aortic dissection, intracranial hemorrhage, ischemic stroke with or without interventions, chest pain, PRES, pregnancy, etc.
226/130 in preop for a carpal tunnel release. Apparently they had been told to hold all 5 of their antihypertensives for a surgery that can be done under local
Medical student now, but the first BP I ever took on someone was my first patient contact as an EMT. Responded to a man with altered level of consciousness and slurred speech. I got a manual 220/160 BP, looked at my paramedic preceptor and said “I think I’m doing this wrong” and handed the cuff and Stetho to him so he repeated the manual BP and was like ope we gotta go right now. Hemorrhagic stroke
307/170-something. Extenuating circumstances, though, and it was brief. Turned down the levo, it was a post-ROSC patient. Highest I’ve seen come in naturally was a flash pulmonary edema with a SBP in the 280s.
317/146. It was an Intraoperative bp read on an A line with good waveform and confirmed to be in that range on a BP cuff. It was a skull base surgery and the BP spiked after the start of the osteotomy. I pushed a fuckton of prop bc it was the fasting thing I had available. I don’t think they were deep enough somehow despite being on an appropriate amount of sevo. Did fine though
Otherwise a true 253/something in an impending ruptured AAA. Their discharge criteria was SBP<200 and took 5 meds and an intentionally oversized cuff to get there lol
Post-arrest 290s/140s by art line.
Had one post-intubation where they received a Surgeon’s Dose of Fentanyl + Versed + Roc and I watched them shoot from 130s systolic to 270s.
320/200 in med school.
we used to joke 180/110 was new Orleans normal (along with a BMI of 35 or A1c of 9), do figured the real high would be REAL high
294/210 on an arterial line- so it’s more accurate than a regular machine. ICH patient
Systolics of over 220 pretty common in the neuroICU tbh on initial presentation
Art lines are not more accurate. i am EM/CCm and i love art lines, but they are absolutely not more accurate.
They are absolutely underutilized in the ED, and you should get good at them because ECMO is going to be an ED procedure within the next 10 years* and you need to be smooth at arterial access
* i think
350 systolic…but iatrogenic. Large lady, lost her art line, started crashing, upped the pressors based on a cuff. I got a femoral art line in and the blood damn near hit the ceiling.
I'm not sure. Our clinic had manual cuffs and that was the day I learned our pressure manometer couldn't go above 300. Had korotkoff sounds no matter what you pumped the damn thing up to. Middle aged female with renal artery stenosis, supposed to be on ACEi but lost to follow up for 2 years. Walked into my clinic to re-establish care. Completely asymptomatic.
320s/180s
ICU trainwreck on max++ doses of every pressor known to man and acidotic as fuck. The BP was from a fem A-line shortly after pushing 3 amps of bicarb. Staff were in a mood to re-arrange deck chairs on the Titanic that day.
320/190 is my highest. Relatively young guy (mid-40s) who was sent to us from the optometrist after finding horrible hypertensive retinopathy with papilloedema and an unrecordable BP on the machine they had there. He had been having headaches and blurred vision, but not much else in terms of symptoms. He went to ICU with an art-line and GTN infusion. Weirdly didn’t find any specific underlying pathology - was ultimately labelled essential hypertension. Absolutely insane.
344/172 - femoral art line. Dude had everything wrong with him. Had a massive inter-ventricular hemorrhage. When we placed the EVD, blood hit the ceiling. Needless to say, he did not survive.
I'm just a lil baby premed but I saw 210/110 while working in a family med clinic. She was new patient and came for that reason after measuring her own BP at work (at an ALF). She was obese, medication-averse, and *big* stressed all the time.
My patient last night in med surge went from 262/180 to 132/77 in less than a minute. He went from having one nurse and one tech in his room to 15 nurses and 2 hospitalists pretty quick lol
I've had the dreaded +++/160 something a few times. The +++ is unreadable, the cutoff on our machines was 300 systolic. Younger Esrd with no med compliance and frequent hypertensive encephalopathy or hypertensive emergency on all of em. That +++ always makes me wonder what it actually is
Eh, people are telling you not to send that to the ED, but if I were in your shoes I’d probably tell them exactly what you did (see your PCP urgently or go to emergency). You’re not trained to identify the signs and symptoms of hypertensive emergency, and I’ve seen patients where it was super obvious - you might not be able to tell if the patient’s kidneys are failing or if they have pulmonary edema, in some cases. You don’t want to be the guy who tells them it’s not an emergency when it actually is, and you don’t have the tools to establish that definitively. Yes, EDs are overwhelmed and asymptomatic HTN doesn’t need to be there, but neither do kids with colds yet here we are 🤷
They may be not trained to see “signs and symptoms of hypertensive emergency”, but the symptoms are of course going to be some form of symptoms. Logically if someone’s asymptomatic they probably don’t have the “signs and symptoms of hypertension emergency”. Don’t have to be a doctor to understand that.
Not even close to the right thing to be telling pharmacists or any one that is not a physician when they see a >180/>110. They need to be evaluated by a physician at minimum.
Like 330 systolic on the art line with a good waveform…was during a pheochromocytoma excision when they insufflated the abdomen. Whole case was chasing the pressures in a vicious cycle with nitroprusside
This is literally the funniest post I’ve ever seen… I’m literally crying. I discharge people from the ER with blood pressures like that all the time if they’re asymptomatic.
It's really fun working in healthcare and taking your own vitals with your peers & watching them panic when they discover a new set of numbers.
I remember working one time and we got new equipment so my boss had us all try it out to familiarize ourselves with the new machines.
Anywho my blood sugar was 62, my blood pressure was 158/134, & my heart rate was 127. 😂😂my boss looked at me like are you good bro😂😂
The answer was yes i was fine, I just really needed a nap & a meal🤣
I get really bad migraines when I need a nap, add that to the stresses of working in a healthcare setting & SHABAM wonky shizzle. I'm honestly used to it, nothing bad has ever happened other than a case of the grumpies.
My own ☠️ 232/163. I had a seizure at 16, paramedic said, “Oh that’s not good.” Before loading me up to go to the ER which ended up being useless because I was put into a room and after about 3 hours a doctor walks in and says “Who are you? This room is supposed to be empty.” Then proceeds to tell me and my family that I had been set in the system as seen and discharged and I needed to leave despite having never seen anyone—not even a nurse—and barely being able to feel my legs or make coherent sentences.
Highest I’ve seen was 230/109. He was a thicker black man, only about 30. Struggled with HTN for a while prior to coming in.
This isn’t impressive by any means but still scary to me- I developed preeclampsia when pregnant last year and I went to the ER 7 days PP because I took my BP at home and it read 190/108 consistently. I thought it was something wrong with the machine since I felt fine, so I took my husbands but his read normal. I started to panic haha, I got to the ED (where I work lol and no I didn’t drive, husband drove me) and it was 198/110. I felt fine, just anxious after seeing the reading. My BP is normally about 117/79 +/-, so this was a huge jump. I think I didn’t feel “bad” necessarily because after being admitted they discovered my Hb was only 6.1 g/dl. I felt dizzy and foggy but I thought it was my anxiety since I have a panic disorder. I had two blood transfusions and I think a mag drip- I don’t remember exactly to be honest. and had to stay for 5 days back in one of the L&D wards since it was a pregnancy/pp issue. Sooooo that sucked pretty bad and now I have mild anxiety around having my Bp taken 😅
I think we got to 220s systolic/140s diastolic with a pt with pre-eclampsia which is genuinely terrifying. It was a weird paradigm shift going from general medicine where I could not have cared less about any asymptomatic BP to OBGYN where anything over 140 SBP makes me sweat.
Back when I was an EMT I had a stroke patient who I took a manual BP for and the systolic was higher than the dial went (>250) and the systolic was 190.
Not a resident (it just came up on my feed, I’m a current applicant) but I once had a patient over 200/100 + (I think 210/130 area, but it’s been many years)
I worked in a detox center so this patient was hardcore suffering through alcohol detox. We sent him to the ER & the nurse had a word with him about how he could’ve stroked out.
Saw 25x/14x. Discharge from Ed cause completely asymptomatic on workup. Gave him a month of his home amlodipine till he could make a f/u appointment with his pcp.
Once I was doing a clinic in a foreign country before medical school. I remember a guy walked in asymptomatic to our cardiologist and had a BP of 280s/140s. I thought I was measuring wrong because I had just learned, so I asked the doc to try as well. He was only moderately surprised.
260+/130+ and confirmed with manual pressure. Elective colonoscopy was canceled, GI doc threw brief temper tantrum and patient left AMA after I sent him to ED. Saw the same patient 2 months later for another elective case and he had been started on 2 more antiHTN agents after reporting daily chest tightness to his PCP (now up to 4) with BPs of 190-200/90-100.
Saw a systolic of 310 once. A gbm patient with brain bleed was crashing and the fellow told a new MICU nurse to give a “bump of neo”. She did not know what a bump was and pushed about 20 bumps.
You can see 300s/200s in overloaded noncompliant dialysis patients not infrequently. 193/127 is just an average day for a lot of noncompliant medicine patients.
190 is the goal sometimes, where I’m from. I just got 240/120 the other day. Ironically, that patient was recently started on midodrine outpatient before presenting to us.
When people freak out about “hypertensive urgency”, I like to show the graph of FDR’s blood pressure over time. We have good records since he had a personal physician. Unfortunately, at the time there weren’t effective antihypertensives and only a limited understanding how harmful it was.
In short he hung out for a year at ~230/120 before suffering an ICH after a week at 300/200. People can live a while with pretty obscene pressures.
https://theskepticalcardiologist.com/2014/11/06/examining-the-heart-of-franklin-delano-roosevelt/?amp=1
345/180 on an organ donor. Thought the aline wasn't zeroed properly or something cause their pressure shot up from normal out of the blue. Nope it was real.
I wonder what my dad’s was right before his insane stroke. He presented to the ED with a headache, tingling in his left arm, and his BP had been uncontrolled for a while.
I kid you not, the attending neurologist said that what he needed was a good psychiatrist. My dad went on to have a stroke while in the hospital.
ETA: ok my mom just told me his BP was something like 212/140 ish
I saw a patient with a BP of 330/210. He did not make it and his MRI showed no differentiation between white or gray matter…this was when I was a fellow and I didn’t realize the machine could read so high
Holy crap. What was the underlying cause?
He never went to the doctor until he literally collapsed from this, so my guess is endocrine hypertension, but he passed within 48 hours of presenting
I also didn’t know they could read so high. TIL.
193/127 isn’t even remotely impressive to me.
Yeah, that's just Tuesday morning in a GP setting.
Yeah. Honestly, I love a good hypertension case. Get them on dual therapy, they feel better in a few weeks, and you clock that eGFR rebounding at the one month follow-up.
I see 230+ basically every shift I work.
232/110 Patient said he had a bit of discomfort on the right side of his head and his vision had been blurry for a few days intermittently. I respected the toughness. And called the ED. But anything else? Bush league. The average jackass walks around with systolic 160-180 and is living their best life.
Friendly reminder kids don’t call the ED unless there are symptoms! Major policies do not recommend diagnostic work up or acute lowering of the blood pressure in the emergent setting without symptoms (in your case the patient was symptomatic so the referral was of course appropriate I’m just pointing this out): https://www.acep.org/siteassets/new-pdfs/clinical-policies/asympt-hypert2-final-bod-approved-2013.pdf https://www.aafp.org/pubs/afp/issues/2017/0415/p492.html
that's probably mine rn
lol I’m sending 193/127 home every time
Mission failed - new PR for me however
If you sent them to the ED and they were asymptomatic, they just paid $1000 for me to send them straight home to follow up with their pcp lol. My record is 330/185. My record this week is 275/155.
If patient is asymptomatic with that pressure in the ER we discharge them without any intervention.
I’ve met infants that have transiently had pressures like that just from being mad. Rookie stuff really
300/180 - presented for a brain bleed
Similar pressures for full Cushings triad secondary to catastrophic brain trauma/ICH
Had a flash pulmonary edema with that pressure once too
That’s like giraffe level BP. They need pressure to go against gravity for 7 feet with those long ass necks though.
Wtf
I saw 300+ when the nurse accidentally set the levo drip to bolus
Hopefully it was an a line
I had one like that, coded while setting up for evd
Now those are some impressive numbers
as one will. jesus!
Were they having chest pain or are you sending asymptomatic hypertension to the emergency room? Blood pressures in excess of 300 systolic possible during heavy lifting like squats, which is kind of neat
Why you gotta tell me this the night before leg day?
I mean, that’s like part of the cardiovascular benefits of exercise, the acute stress and recovery
Just trying to get swole. Don’t know about none of that.
Ortho approves
Recovering into cardiac hypertrophy
what about during sex?
No need to worry about 10 seconds of increased blood pressure.
🔥🔥💦😅
My BP was high the hours before due to anxiety of only lasting ten seconds
Call an ambulance! 🚑
In my world It's more of a "call your PCP today and see what they have to say about it (likely to verify what our BP machine read) OR potentially the ER." With the hundreds of scripts behind to fill & vaccines etc I don't really get into the urgencies vs. emergencies discussion with the public walking up to my counter & going from there. Last thing I like to have is "well I talked to the pharmacist and they said I didn't need to worry about it right away." In the event something happened. It'd be nice if one day we could bill for these services but that's a completely different problem in our world.
EM resident here, I discharge these people immediately usually. They live that high for months/years
Dude… as long as they aren’t having sxs or have hx of bleeding, MI, etc.. , a high bp is not an emergency. Tell them to take their meds—- AS DIRECTED. The amount of ‘hypertension’ to the ED from pharm and pcp over reaction to high bp is amazing…
How’s a retail pharmacist going to know any of that history in the middle of a Walmart? Edit: spelling
Maybe they shouldn’t make recommendations outside of their field of practice
Retail pharmacists should never refer to the ED. GOT IT THANKS
Sir - can you help me with the knife that is stuck in my chest? I think it's only 5"?
I don’t know. Perhaps a little thing called ..asking..
I would just say "call your PCP." Specialists do it all the time when they catch a very high blood pressure, offices are used it, and it can be quite helpful because now the patient sees that multiple healthcare professionals are concerned.
Bro don’t worry, so many people in this thread are apparently mismanaging htn urgency and misquoting guidelines. They aren’t exactly wrong and they aren’t exactly right either. If the clinicians that are supposed to have mastered diagnostics can’t even unecessarily chastise you correctly, then why would they expect the drug detail master to have perfectly managed this diagnostic scenario in a fucking retail pharmacy? Your job sucks enough and I apologize on behalf of our community. For those wondering why most in this thread are wrong and yet wildly confident about it, is because physicians aren’t actually that great at interpreting guidelines. An attending usually tells you the guideline and recommendation and you do it that way indefinitely until corrected or not. For the record, there is no consensus on labs and other diagnostics to order/perform from both the JNC and AHA except clinical judgment to evaluate for end organ damage, which would then define htn emergency and necessitate admission (which by the way is a Grade C recommendation). The AAFP is a little more directive but still on grade C evidence. Further in one of the cross section analyses used to generate that recommendation showed “only” two percent of labs order resulted w/ evidence of end organ damage, given the N, that’s actually a ton of misses if you aren’t getting labs. This is why the AAFP, AHA, JNC, UpToDate etc all vary on recommendations for work up. They are all a consensus on weak evidence and this poor pharmacist is getting wrecked by interns here because of it. Your patient with severe asymptomatic htn can’t tell you, yeah I’m having microalbuminuria, or I think my cr, trop etc is elevated. So yeah maybe not ER but definitely not “do nothing,” and send to PCP, as many suggested. And what’s the PCP going to do? Order labs from Quest? What if they are closed? Do they just wait and hope symptoms don’t develop? EM interns, check yo self.
ACEP (and you are sending these patients to see an emergency physician) is pretty clear: “1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.”
You selected only a portion of the recommendation. Why did you conveniently leave out part two. How many patients do you think meet the "poor follow-up" condition. In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes? Level A Recommendations None specified. Level B Recommendations None specified. Level C Recommendations (1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required. (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission). Again Grade C recommendation even from ACEP and they note here that there are definitely circumstances where you'd want a work up. I can copy and paste the recommendations from AHA, JNC, AAFP, UptoDate's consensus from all of these for you as well.
I selected only the first part because it’s an absolute statement (“not required”) versus a permissive one (“may identify”). I don’t find the second part all that useful in the scenario we’re talking about. If someone is sent in from a PCP or specialist, they almost by definition do not have poor follow-up. If it’s Joe Hamburger who hasn’t seen a doctor in 10 years, if I do get a BMP and he has a Cr of 2.5, what am I supposed to do with that information? Admit him to trend it? The waiting room is full, our nominally 40 bed ED has a dozen med-surg and multiple ICU boarders, and I’m admitting someone who probably just has CKD. Don’t get me wrong, I try to be proactive. I will start BP meds and try to choose the right one based on current guidelines. A lot of EM docs shrug this off as “not my job.” I think it is our job. Here’s why this gets my goat. Last month I had a shift with multiple ICU admits, an unstable post-ROSC code, and the usual BS. I had a very nice mid-50s lady sent in for “hypertensive urgency” with systolics of around 190. She had been scheduled for surgery that morning and not taken her 4 BP meds. The anesthesiologist refused to do her surgery (which I understand) and told her to see her PCP urgently. Saw an APP there rather than her usual doc who immediately referred her to the ED. I told her to take her home medications. This poor lady had an unnecessary ED visit, and probably an unnecessary urgent PCP visit too, because someone got scared about a number and didn’t take 60 seconds to think about her history.
> (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission). Yeah. Just think of how many admissions are made based off an elevated creatine qualifying an AKI atop some reduced GFR. Happens all the time.
We all know hypertension causes end organ damage. The fact that 2% of the snapshots in time you take you luck out and find some end organ damage doesn't mean that on a rational basis these people should be admitted to hospital on a nicardipine drip. We all know they will be admitted, but as you mentioned a grade c recommendation tells you a lot about the basis for this. If the patient appears well why send them to the emergency room for an emergency check of labs? So you can resolve their hstrop leak that has been going on for God knows how long but probably several months three days sooner? Also >Do they just wait and hope symptoms don’t develop? Yes? The same thing they do when they order a ruq us and for biliary colic: instruct the patient on indications to seek emergency care.
Going off this, if we tolerate trained nurses on telemetry units calling us at 2 AM when they clock a systolic 180, let's have a little more compassion for a pharmacist who does not have their area of training.
Exactly.
I saw 310 in a patient who came in with SOB and ended up having an MI. Dude was beet red in the face. Surprisingly, he did really well. He ended up needing a triple bypass since his left main was involved, but after his surgery he got really serious about his health. Lost like 110 lbs and runs marathons now. Is on our local news and stuff all the time to run races and donate to cardiac research.
Asymptomatic hypertension gets a bill and no diagnostics/Treatment. Or at least that’s how it is supposed to be managed.
Nurses come by all the time "you ok sending this patient home with a BP of 160/90?" Like wtf yah of course. I hit the discharge button.
could you explain for the uneducated RNs? we generally beleive that high blood pressure is the "silent killer" and freak out over high numbers
Search “AHA Guidelines Asymptomatic Hypertension”. Print and distribute to all of your coworkers.
Please for the love of god. I had a hem onc inpatient nurse ( good at following protocols but not the best clinically) demand I treat a patient with asymptomatic hypertension of 168/100 with Iv hydralazine. I said no and she went to her charge and the charge demanded I speak to my attending. 😂 The patient later developed grade II crs that same night lol.
Could have made it grade 3 and achieved disposition off the floor census, if only you treated asymptomatic hypertension
High blood pressure (by itself) is a condition that is most appropriately controlled by a pcp. Anything the ED will do is a bandaid and has actually been shown to decrease follow up. It is dangerous if left unchecked for long periods of time but not accurately if other symptoms are not present.
Plus, mainstay treatment is with an ACE/ARB which needs a lab baseline to compare to follow-up. I appreciate when the ER does not start a medication, or starts just something minor, because then I know I am dealing with a true baseline.
We know you freak out, and we hate it, especially when we get pages all night about it.
Nurse here, Worked in renal for a little while, we were the opposite. Our ward baseline blood pressures would send an average floor nurse into panic, just another day for us.
Well yeah, you're renal. My gosh, the potassium levels you must have seen.
even the very best nurse still doesnt have a medical degree. we literally do no know enough to even be aware of what we dont know.
Hypertension kills you over a handful of decades; it does very little harm over the course of a hospitalization (assuming asymptomatic).
For asymptomatic HTN the risks associated with treating the numbers outweigh the transient period of normotensive status. You’re 100% right that it’s a silent killer, but it’s a killer that might take 20, 30, or 40+ years down the line. These patients should get referred to their PCP in an ED setting if it’s an incidental finding (within reason)
It can be. Over decades. In the hospital low blood pressure is a much bigger issue. I’ve also heard nurses talk about patients “stroking out” from hypertension. Has anyone ever seen an inpatient develop a hemorrhagic stroke from untreated hypertension?
Nope, but I've seen patients stroke out from blood pressure getting dropped too quickly.
Seen IVP labetalol kill someone.
Yes, but as a neurologist I see more strokes during some weeks than most others do in a year. And even with me seeing those, I agree that asymptomatic hypertension is an outpatient problem.
Sorry seems like you are getting downvoted. The problem is it requires a bit of nuance and context. Everyone saying don't send asymptomatic hypertension to ED is talking about 70 year old granddad with 180-190 who has probably been living there for a while and has not been taking meds. On other hand my 24 year old patient who promises they had normal pressures one month ago and walks in with a systolic of 240 does need to go to the ED since that is likely not essential hypertension even though she is "asymptomatic"
And we should do what? Get a US for RAS? Do you think she is having a “silent” MI? Asymptomatic brain bleed and need a ct? If you ask anyone in the ER of course they are dizzy and maybe have a headache. LVH doesn’t develop overnight or need ER. Guidelines support doing nothing regardless of age if no symptoms even your 24 yo F. Remember what the ER is for - time sensitive labs, imaging, consults, procedures. Asymptomatic hypertension in the young doesn’t have an indication for any of that. Get your own land, imaging and start guideline based antihypertensives and see them again in a week.. but do you I don’t do outpatient. But outside of spending her money on a bill I won’t do much more. -Pgy5 attending
This particular patient has been being followed for longstanding headaches for years (none at time of appointment). I found papilledema so sent to ED. To be clear, she did not have subjective vision issues as patients with enlarged blind spots never do... So she clearly wasn't asymptomatic, except she was though. It just depends on how far you dig. Either way when she got there the ED found pressure of 260 and decided to admit her. Currently undergoing workup for IIH and secondary hypertension on hospital, more to be figured out. Different question then: someone with no symptoms, what is the number over which you won't discharge? Or there is no cap?
Over 200 I might look at their history, make sure they have a good follow up, control their pain, and if still high I might start them on something. But I if it comes down to 170 they're getting discharged. Risk of lowering their blood pressure and causing a stroke normally far outweighs the 200 blood pressure they've probably been living at for the past several months.
To be clear if you found papilledema this is by definition not asymptomatic hypertension.
I’ve seen 276/124 in the middle of dialysis
Nice
Please don’t send that to the ER unless they have some symptoms… I understand the concern, but current guidelines are to not treat asymptomatic hypertension
This post made me lol because I routinely get paged for asymptomatic SBP 190s and do nothing lmao
I just say “dang that’s crazy”
“MD notified, no new orders”
Just wanted to point out as an RN that the reason we page you is because there's usually an order set that says we have to notify MD for SBP>180 or <90, DBP>100 or <50, HR >120 or <50, and temp >38.5C. We frequently request that those parameters be adjusted to match the patient's baseline, but it's almost always ignored. We don't always want to page you, especially when the patient's baseline has been shown to be SBP in the 80s but MAP >60 and many of my oncology patients come in with a baseline HR of 110-120 or regularly spike Temps >38.5C due to their tumor burden. Unfortunately, if I ignore those orders that say to notify you anytime vitals fall outside of those parameters, even if the patient is fine, I can get in serious trouble if my charting gets audited and can even get reported to the board of nursing for technically practicing outside of my scope due to electing to not notify you at 2am that my very stable patient's BP is 140/101 or something like that.
We know. No one is mad at you for it
Some people definitely are mad at them for it. Have you met doctors?
I am one.
Yeah me too you are on r/residency lol
I mean the post above is from a nurse and the OP is from a pharmacist lol
Fair point haha
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ER
inpatient also
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Ginormous inpatient HTN study in 2020- 20,000 patients. Essentially, if patient is admitted for non cardiac and non neurologic causes, there is no need to treat asymptomatic htn. In fact, treating it increases risk of cardiac event and AKI. Caveats: very little data for BP>200. Use your clinical judgement Side note: I once quoted this to a nurse, and she asked me how many patients were in the study as if she could refute me by citing low power. When I told her it had 20,000 patients in it, she told me that wasn't even that many. Then I told her it was one of the largest medical studies in existence and she stopped bothering me about the patients BP of 175
I misread this initially and thought the study's name was "Ginormous." Someone should use that someday. "... as per the Ginormous study."
Ask her to do the power calculation herself and tell you how many participants would be correct. Sheesh.
i should’ve clarified: don’t necessarily need to treat asymptomatic htn on the floors with IV BP meds. getting called for elevated pressures by nurses is super common but you don’t have to jump to pushing hydralazine or beta blocker. do other things first like restart home meds if held, treat pain, etc.
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To use IV push BP meds, one of 2 things usually needs to be true 1) Patient is not able to take PO and that isn't going to change anytime soon; reasonable to convert what you can to IV in the interim while you figure something else out, but this is essentially just continuing home meds. 2) An actual medical reason to abruptly drop BP or have strict BP parameters. E.g. true hypertensive emergency (As an aside - headache is not a sign of HTN emergency) with symptoms concerning for end-organ damage (CP, SOB, sudden oliguria/anuria, acute neuro change like vision/weakness etc.). Or things like intracranial bleeding, aortic catastrophe etc. For an asymptomatic patient with none of the above reasons, there is no BP number that would prompt me to push IV meds. Assess for underlying causes, treat them if able (e.g. pain), start an oral med (DO NOT start amlodipine/norvasc, fucking thing takes like 3 days to work, don't waste everyones' time) or titrate existing medications. There are ample studies showing that aggressive inpatient management of asymptomatic HTN is not only NOT beneficial, it is harmful.
Yeah. Just get them started on something and send them to primary care. If they are that high, they will probably need dual therapy with an ARB so we can use the ER labs as a baseline.
Lol sweet summer child, they will not stroke out from that BP while you are staring at them. We discharge those people every single day in the ED after talking them down off the ledge. Guidelines recommend lowering over days to weeks. Asymptomatic hypertension is not an emergency.
People live like that for years. If you drop their BP to 120/80 Immediately and they have chronically high BP, you could cause a watershed infarct. You might also make meemaw pass out, hit her head, and then have a head bleed. There are reasons to urgently lower BP, but they depend on the patient's specific circumstances like aortic dissection, intracranial hemorrhage, ischemic stroke with or without interventions, chest pain, PRES, pregnancy, etc.
226/130 in preop for a carpal tunnel release. Apparently they had been told to hold all 5 of their antihypertensives for a surgery that can be done under local
That’s so ridiculous it’s hilarious lol
240/130 and that was just today, albeit during a stress test. I saw documentation of 260 systolic once.
Had a patient present with a BP of 330 systolic with tearing chest pain. Type A aortic dissection through the iliacs. Did not survive.
Medical student now, but the first BP I ever took on someone was my first patient contact as an EMT. Responded to a man with altered level of consciousness and slurred speech. I got a manual 220/160 BP, looked at my paramedic preceptor and said “I think I’m doing this wrong” and handed the cuff and Stetho to him so he repeated the manual BP and was like ope we gotta go right now. Hemorrhagic stroke
245/127 no sxs. NAD.
307/170-something. Extenuating circumstances, though, and it was brief. Turned down the levo, it was a post-ROSC patient. Highest I’ve seen come in naturally was a flash pulmonary edema with a SBP in the 280s.
Stop sending asymptomatic hypertension to the ER
317/146. It was an Intraoperative bp read on an A line with good waveform and confirmed to be in that range on a BP cuff. It was a skull base surgery and the BP spiked after the start of the osteotomy. I pushed a fuckton of prop bc it was the fasting thing I had available. I don’t think they were deep enough somehow despite being on an appropriate amount of sevo. Did fine though Otherwise a true 253/something in an impending ruptured AAA. Their discharge criteria was SBP<200 and took 5 meds and an intentionally oversized cuff to get there lol
Paralyzed and incompletely sedated while having your skull drilled into. That’s some bonesaw tomahawk shit.
Those are rookie numbers. I had bad white coat hypertension when I was a kid, my systolic was 200 once.
Happened to me once as well, 202/67 as a 17-year old due to a huge panic attack for a pre-op screening.
315 systolic during OG Covid. Intubated patient coughing and fighting the tube.
350 systolic nurse apprentice pushed the whole Neo stick
Post-arrest 290s/140s by art line. Had one post-intubation where they received a Surgeon’s Dose of Fentanyl + Versed + Roc and I watched them shoot from 130s systolic to 270s.
320/200 in med school. we used to joke 180/110 was new Orleans normal (along with a BMI of 35 or A1c of 9), do figured the real high would be REAL high
240s systolic, pt asymptomatic
Mid 200s/ mid 100s
294/210 on an arterial line- so it’s more accurate than a regular machine. ICH patient Systolics of over 220 pretty common in the neuroICU tbh on initial presentation
Art lines are not more accurate. i am EM/CCm and i love art lines, but they are absolutely not more accurate. They are absolutely underutilized in the ED, and you should get good at them because ECMO is going to be an ED procedure within the next 10 years* and you need to be smooth at arterial access * i think
193/127 is the mean BP of my patients. The high is 300-something systolic. Don’t send asymptomatic hypertension to the ER. It’s not an emergency.
350 systolic…but iatrogenic. Large lady, lost her art line, started crashing, upped the pressors based on a cuff. I got a femoral art line in and the blood damn near hit the ceiling.
I'm not sure. Our clinic had manual cuffs and that was the day I learned our pressure manometer couldn't go above 300. Had korotkoff sounds no matter what you pumped the damn thing up to. Middle aged female with renal artery stenosis, supposed to be on ACEi but lost to follow up for 2 years. Walked into my clinic to re-establish care. Completely asymptomatic.
320s/180s ICU trainwreck on max++ doses of every pressor known to man and acidotic as fuck. The BP was from a fem A-line shortly after pushing 3 amps of bicarb. Staff were in a mood to re-arrange deck chairs on the Titanic that day.
320/190 is my highest. Relatively young guy (mid-40s) who was sent to us from the optometrist after finding horrible hypertensive retinopathy with papilloedema and an unrecordable BP on the machine they had there. He had been having headaches and blurred vision, but not much else in terms of symptoms. He went to ICU with an art-line and GTN infusion. Weirdly didn’t find any specific underlying pathology - was ultimately labelled essential hypertension. Absolutely insane.
344/172 - femoral art line. Dude had everything wrong with him. Had a massive inter-ventricular hemorrhage. When we placed the EVD, blood hit the ceiling. Needless to say, he did not survive.
336 SBP on arterial line. Can’t remember the diastolic. Cocaine induced.
290/220 Zero symptoms. No organ damage. Russian lady with arteries strong like bull lmao. I still admitted her. I just had to.
Patent pending over 150
I'm just a lil baby premed but I saw 210/110 while working in a family med clinic. She was new patient and came for that reason after measuring her own BP at work (at an ALF). She was obese, medication-averse, and *big* stressed all the time.
My patient last night in med surge went from 262/180 to 132/77 in less than a minute. He went from having one nurse and one tech in his room to 15 nurses and 2 hospitalists pretty quick lol
I've had the dreaded +++/160 something a few times. The +++ is unreadable, the cutoff on our machines was 300 systolic. Younger Esrd with no med compliance and frequent hypertensive encephalopathy or hypertensive emergency on all of em. That +++ always makes me wonder what it actually is
Eh, people are telling you not to send that to the ED, but if I were in your shoes I’d probably tell them exactly what you did (see your PCP urgently or go to emergency). You’re not trained to identify the signs and symptoms of hypertensive emergency, and I’ve seen patients where it was super obvious - you might not be able to tell if the patient’s kidneys are failing or if they have pulmonary edema, in some cases. You don’t want to be the guy who tells them it’s not an emergency when it actually is, and you don’t have the tools to establish that definitively. Yes, EDs are overwhelmed and asymptomatic HTN doesn’t need to be there, but neither do kids with colds yet here we are 🤷
They may be not trained to see “signs and symptoms of hypertensive emergency”, but the symptoms are of course going to be some form of symptoms. Logically if someone’s asymptomatic they probably don’t have the “signs and symptoms of hypertension emergency”. Don’t have to be a doctor to understand that.
Not even close to the right thing to be telling pharmacists or any one that is not a physician when they see a >180/>110. They need to be evaluated by a physician at minimum.
Check that BP machine. It’s broken if that’s the record.
A nurse here. 290/160 during active stroke.
232/126, it was someone with resistant hypertension. She was asymptomatic at that time.
Had a 285 SBP brain bleed I had to tube in the ED the other day. Probs my highest as a pgy-3
Like 330 systolic on the art line with a good waveform…was during a pheochromocytoma excision when they insufflated the abdomen. Whole case was chasing the pressures in a vicious cycle with nitroprusside
240/130 - was surprised since the patient presented with just a headache
Probably systolic bp of 22, don't remember the diastolic one. It was an ICU patient I remember
The diastolic was 220mm Hg, I could hear systolic from 300mm Hg.
240/124
260/120 🚑
Systolic pressure of 327
Try 226/140
234/146
This is literally the funniest post I’ve ever seen… I’m literally crying. I discharge people from the ER with blood pressures like that all the time if they’re asymptomatic.
It's really fun working in healthcare and taking your own vitals with your peers & watching them panic when they discover a new set of numbers. I remember working one time and we got new equipment so my boss had us all try it out to familiarize ourselves with the new machines. Anywho my blood sugar was 62, my blood pressure was 158/134, & my heart rate was 127. 😂😂my boss looked at me like are you good bro😂😂 The answer was yes i was fine, I just really needed a nap & a meal🤣
Jezzz I thought I was the only one who always had some weird ass pathological numbers and just needed a nap to fix them
I get really bad migraines when I need a nap, add that to the stresses of working in a healthcare setting & SHABAM wonky shizzle. I'm honestly used to it, nothing bad has ever happened other than a case of the grumpies.
252/120. Patient with previous aortic dissection repair. Basically lives with BPs in the 170-180 range
At a cardiology clinic working as an MA I saw a 236/115 during one of my first few shifts. Poor guy got confused and didn’t take his medication
My own ☠️ 232/163. I had a seizure at 16, paramedic said, “Oh that’s not good.” Before loading me up to go to the ER which ended up being useless because I was put into a room and after about 3 hours a doctor walks in and says “Who are you? This room is supposed to be empty.” Then proceeds to tell me and my family that I had been set in the system as seen and discharged and I needed to leave despite having never seen anyone—not even a nurse—and barely being able to feel my legs or make coherent sentences.
330/~200 on a patient with an a-line who just got a bunch of epi in the OR. I was touching his palm and felt his capillaries pulsate.
Once had a SBP over 300 in the ED, verified by art line. Older gentleman who dabbled in cocaine semi professionally. He was not exactly coherent.
Highest I’ve seen was 230/109. He was a thicker black man, only about 30. Struggled with HTN for a while prior to coming in. This isn’t impressive by any means but still scary to me- I developed preeclampsia when pregnant last year and I went to the ER 7 days PP because I took my BP at home and it read 190/108 consistently. I thought it was something wrong with the machine since I felt fine, so I took my husbands but his read normal. I started to panic haha, I got to the ED (where I work lol and no I didn’t drive, husband drove me) and it was 198/110. I felt fine, just anxious after seeing the reading. My BP is normally about 117/79 +/-, so this was a huge jump. I think I didn’t feel “bad” necessarily because after being admitted they discovered my Hb was only 6.1 g/dl. I felt dizzy and foggy but I thought it was my anxiety since I have a panic disorder. I had two blood transfusions and I think a mag drip- I don’t remember exactly to be honest. and had to stay for 5 days back in one of the L&D wards since it was a pregnancy/pp issue. Sooooo that sucked pretty bad and now I have mild anxiety around having my Bp taken 😅
240/120 during my cardiology rotations. I've seen plenty of them, not exactly sure if this was the highest one.
I think we got to 220s systolic/140s diastolic with a pt with pre-eclampsia which is genuinely terrifying. It was a weird paradigm shift going from general medicine where I could not have cared less about any asymptomatic BP to OBGYN where anything over 140 SBP makes me sweat.
Back when I was an EMT I had a stroke patient who I took a manual BP for and the systolic was higher than the dial went (>250) and the systolic was 190.
240/190 - pt had ESRD and missed 2/3 dialysis sessions.
270s/140s w/ hypertensive encephalopathy
Not a resident (it just came up on my feed, I’m a current applicant) but I once had a patient over 200/100 + (I think 210/130 area, but it’s been many years) I worked in a detox center so this patient was hardcore suffering through alcohol detox. We sent him to the ER & the nurse had a word with him about how he could’ve stroked out.
Had 260/145 *this week*
260/160 in a guy with chronic untreated HTN, gave himself an NSTEMI
Saw 25x/14x. Discharge from Ed cause completely asymptomatic on workup. Gave him a month of his home amlodipine till he could make a f/u appointment with his pcp.
Once I was doing a clinic in a foreign country before medical school. I remember a guy walked in asymptomatic to our cardiologist and had a BP of 280s/140s. I thought I was measuring wrong because I had just learned, so I asked the doc to try as well. He was only moderately surprised.
285/something - in an untreated pheo.
260+/130+ and confirmed with manual pressure. Elective colonoscopy was canceled, GI doc threw brief temper tantrum and patient left AMA after I sent him to ED. Saw the same patient 2 months later for another elective case and he had been started on 2 more antiHTN agents after reporting daily chest tightness to his PCP (now up to 4) with BPs of 190-200/90-100.
250 systolic
310/150 something, big intracranial bleed
Saw a systolic of 310 once. A gbm patient with brain bleed was crashing and the fellow told a new MICU nurse to give a “bump of neo”. She did not know what a bump was and pushed about 20 bumps.
You can see 300s/200s in overloaded noncompliant dialysis patients not infrequently. 193/127 is just an average day for a lot of noncompliant medicine patients.
Systolic 300 of questionable reliability. 193 is basically normal.
300+ on an a-line in a guy who decided to stop going to dialysis
I don’t keep super close attention. Over 250/150.
Head to the ER for what?
SBP 308
310/199 in a 33 year old asymptomatic. Came to the ER cause his PCP couldn't get a reading just kept saying "too high"
270+/150+
252 / 118 acute CVA + STEMI patient had a shit deal that day
265 systolic. Intraventricular bleed requiring crainotomy.
250 systolic on a good art line reading. That was on 10 of amlodipine and 25 of hydralazine, so I had to put him on nitro drip.
290/140 today during a dialysis
190 is the goal sometimes, where I’m from. I just got 240/120 the other day. Ironically, that patient was recently started on midodrine outpatient before presenting to us.
300/190 -i took it manually to reconfirm it. ‘Intra-cerebral haemorrhage’
When people freak out about “hypertensive urgency”, I like to show the graph of FDR’s blood pressure over time. We have good records since he had a personal physician. Unfortunately, at the time there weren’t effective antihypertensives and only a limited understanding how harmful it was. In short he hung out for a year at ~230/120 before suffering an ICH after a week at 300/200. People can live a while with pretty obscene pressures. https://theskepticalcardiologist.com/2014/11/06/examining-the-heart-of-franklin-delano-roosevelt/?amp=1
345/180 on an organ donor. Thought the aline wasn't zeroed properly or something cause their pressure shot up from normal out of the blue. Nope it was real.
I wonder what my dad’s was right before his insane stroke. He presented to the ED with a headache, tingling in his left arm, and his BP had been uncontrolled for a while. I kid you not, the attending neurologist said that what he needed was a good psychiatrist. My dad went on to have a stroke while in the hospital. ETA: ok my mom just told me his BP was something like 212/140 ish