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HYPERTENSION

Paramedic Class 108


Introduction
• Incidence
• 50 million Americans
• 1 in 5 Americans or 18%
• Undiagnosed 15 million (30% of the 50 million)
• 1 in 18 Americans or 5%
• Morbidity/Mortality
• Gender – Male=49.7. Female=50.3
• Death Rate (per 100,000) – White Males=14.4,
Black Males=49.6, White Females=13.7, and Black
Females=40.5.
Group 1 Assignment
• Define Blood Pressure
• Define Systolic blood Pressure: Normal
• Define Diastolic Blood Pressure: Normal
• What are blood pressure perimeters
that indicate high pressure.
• What are some factors that determine
blood pressure. Formula
• What factors may affect blood pressure
determination.
Blood Pressure Regulation
Mechanisms
• Autonomic
Nervous
System
• Kidneys (Renin-
Angiotensin-
Aldosterone)
• Endocrine
System
RENIN
• An enzyme released by the kidney that
stimulates production of angiotensin.
• A protein secreted by the kidneys that
raises blood pressure back to normal
when it begins to fall.
ALDOSTERONE
• The main electrolyte-regulating hormone
secreted by the adrenal cortex: primarily
controls sodium and potassium balance.

• Released by the adrenal glands that


increases blood pressure by signaling the
kidneys to retain sodium, which increases
blood volume.
Angiotensin
• A peptide that is produced by a
biochemical reaction caused by the
enzyme Renin.
• Hormone that has two forms: angiotensin
I which is inactive and angiotensin II
which is the active form. The latter raises
blood pressure by causing arteries to
constrict and triggering the release of
aldosterone.
Renin-Angiotensin
KNOW THIS
• Renin stimulates formation of angiotensin I:
• Then converts to angiotensin II

• Angiotensin II is a potent vasoconstrictor


• Stimulates ADH secretion

• Results in:
• Reabsorption of sodium and water
• Elevation in blood pressure
• Activation of renin-angiotensin system
ADH
• ADH is a hormone released by pituitary
gland but made elsewhere (in the
hypothalamus). ADH has an
antidiuretic action; it suppresses the
rate of urine production. ADH is also
known as vasopressin.
Blood Pressure Regulation
Mechanisms
• Autonomic Nervous System
• Baroreceptors – Measure stretch (heart,
great vessels)
• Chemoreceptor's – Measure hypoxemia,
acidosis…pH & PO2 (carotid, aortic
bodies)
• Results in vessel dilation or constriction
Blood Pressure Regulation
Mechanisms
• Kidneys (Renin-Angiotensin-Aldosterone)
• Decreased BP
• Renin secreted by kidneys. Works on angiotensinogen to
produce angiotensin I
• Angiotensin I converted to angiotensin II by angiotensin
converting enzyme (ACE)
• Vasoconstriction & secretion of aldosterone and ADH
(AKA: Vasopressin)
• Results in water and sodium retention and higher blood
pressure
Blood Pressure Regulation
Mechanisms
• Kidneys (Renin-Angiotensin-Aldosterone
Group 2 Assignment
• Sketch the Renin – Angiotensin –Aldosterone
mechanism.
Group 3 Assignment
Define
• Hypertrophy
• Myocardial hypertrophy
• Starlings Law
• Peripheral Vascular Resistance
CHF, HTN, & Renal Failure
• Long term untreated HTN leads to
hypertrophy (LV).
• The Starling effect is compromised and the LV
is not fully emptied during systole.
• Decreased Stroke Volume (SV) and Cardiac
Output (CO).
• Blood backs up causing CHF
• Less cardiac output = major organs (vessels,
kidneys, brain, eyes) not adequately perfuse
• Cells are then damaged, begin to fail, and die
Hypertension Development
Recognized Factors
• CAD
• Age
• Heredity
• Ethnicity
• African-Americans,
Puerto Ricans, Cubans,
Hispanics
• Diet
• Cholesterol
• Fats
• Sodium
• Weight
• Obesity
• Smokeless Tobacco Users
• Stress/Type A
Personalities
Hypertension Etiology
Primary Hypertension
• No specific identifying cause
• Arteriole wall vasoconstriction, wall damage
• Many risk factors
• Develops over years
• May or may not be symptomatic
• Treatment aimed at lowering BP through diet
and medications
• Patient Home Medications - Cardiac
Hypertension Etiology
Primary Hypertension
• Patient Home
Medications – Cardiac
• Beta Blockers
• Calcium Channel
Blockers
• Adrenergic Inhibitors
• ACE Inhibitors
• ARBS
• Diuretics
Group 4 Assignment
Home Medications
Describe the therapeutic actions for each
class & identify several medications
that are used.
• Beta Blockers
• Calcium Channel blockers
• ACE Inhibitors ACE?
• ARBS –ARBB?
• Diuretics
Hypertension Etiology
Secondary Hypertension
• Often has an identifying cause
• 10% of hypertension cases
• Abrupt onset
• Commonly renal in origin
• Renal artery stenosis
• Polycystic disease
• Fibro-muscular disease of renal artery
• Adrenal tumors
Anatomical Damage from
Hypertension
• Vessels
• Kidney
• Brain
• Heart
Anatomical Damage from
Hypertension
• Vessels
• Large vessels – Sclerosis (hardened)
• Narrowed lumen – tunica media
hypertrophy, tunica intima with
endothelium damage (allows
vascular content leakage)
• Lose of elasticity
• Decreased blood flow
• Occlusion, tear, rupture (aneurysm)
• Increased PVR
• Aorta – Weakens and leads to
aneurysms
• Small vessels
• Damage to intima layer
• Scar tissue
• Fibrin strands/clot formation
• Obstruction
Anatomical Damage from
Hypertension
• Kidney
• Poor perfusion leads to
organ damage
• Decreased function…failure
• In many cases, leads to renal
dialysis
Anatomical Damage from
Hypertension
• Brain
• Stroke/CVA – Cerebral Vascular Accident
• TIA – Trans Ischemic Attack
Anatomical Damage from
Hypertension
• Heart
• As described earlier
• AMI
• Vessel obstruction from poor blood
flow (coronaries)
• Hypertrophy
• Outgrows blood supply
• Smaller chamber size
• Decreased CO – Incomplete LV
emptying
• CHF – Congestive Heart Failure
(result of increased PVR)
• Poor perfusion of other organs,
related to CO
Pre-hospital Hypertensive Crisis
• Pathophysiology can cause intercerebral or
subarchnoid bleeding and cerebral infarcts
• Cerebral edema
• BP generally greater than 100 mmHg diastolic
• Other key organs can be damaged as well
• Common cause is sudden discontinuation of
HTN medications
• Pregnancy Induced Hypertension is a
common cause (5% of pregnancies)
Pre-hospital Hypertensive Crisis
• Signs/Symptoms – • AMI
Marked BP Elevation
• Headache • Arrhythmias
• Nausea
• EKG
• Vomiting
• Confusion monitoring
• Restless • Nosebleeds
• Seizure
• Stroke • Airway issues
• Coma
• Frequent LOC checks
Pre-hospital Hypertensive Crisis
Management
• Rapid lowering of BP can be dangerous
• Slow lowering (2-6 hours) of BP is preferred
• Ischemia and infarct is possible
• Nitroprusside
• Nitroglycerine is not preferred in the EMS environment
• Pre-hospital therapies:
• Airway control, as needed
• Calm, reassure patient
• Oxygenation & Ventilation
• IV – TKO
• EKG Monitoring
• LOC reassessment
• Vital signs
Long Term Treatment of
Hypertension
• Slight decrease (5%) in BP will decrease the
risk of stroke by 35-40%
• Adequate treatment of high blood pressure
will decrease:
• Heart failure 52% (Higher risk for CHF)
• Often develops into CHF 91%
• Stroke 38%
• LV Hypertrophy 35%
• Cardiovascular Mortality 21%
Hypertension Prevention &
EMS Role
• EMS has a role in educating the public
• Prevention Programs
• On-scene Education
Hypertension Prevention &
EMS Role
• What to educate:
• Lifestyle changes @ early age
• Good diet
• Reduce cholesterol, lipids, and triglyceride levels

• Exercise
• Avoid tobacco
• Take prescribed medications
Hypertension Prevention &
EMS Role
• EMS Activities
• FD station BP checks, educate as needed
• Organized healthcare screenings, educate
as needed
• On-scene treatment and education
Group 5 Assignment
Scenario:
58 yo female c/o HA dizzy. Ran out of
Meds . Propranolol, captopril,
valsartan, furosmide, nitroglycerin
Are the medications cardiac related?
VS. 198/110 92 irreg. 16 non labored
Patient History?
Your Treatment?
REVIEW

Hypertension
Signs
&
Symptoms
QUESTIONS?

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