"Cardiac protocol" in the ER?

Factual Questions
1

Last Wednesday, I got to call 911 when my dad started showing abrupt signs of a possible stroke. He was taken by ambulance to the nearest ER, where they assessed him, took an EKG, sent him for a CAT scan, did some blood work, and finally admitted him for observation.

He ended up having a trans-ischemic attack (that is, the clot hit, did damage, and then went away) and is home, recuperating.

There was something, though, during his time in the ER that really bothered me, especially because it didn’t make sense to me.

He has a history of primary, malignant hypertension. He’s on five classes of hypertension medications. He has a pacemaker due to bradycardia from all the medications he takes. He has rampant atherosclerosis, a history of throwing clots from his carotid arteries to his brain, and on top of that, he has a 4.0 cm aortic abdominal aneurysm. That day, he missed his mid-day medications completely, as his onset of symptoms occurred just before he’d have taken them, and if you go to the ER for anything, you pretty much have to expect not to be given anything to eat or drink while you’re there.

His cardiologist has told us to keep his blood pressure below 150/70, which we mostly manage to do. If it goes above 180, we stop whatever we’re doing, stuff clonidine down his mouth and check him frequently. If it doesn’t come down in an hour, we’re off to the ER.

Yet, while he was there, his blood pressure started in the 190s and spiked all the way up to 225/105 - something I’d never seen.

I asked the nurse about it, saying Dad hadn’t gotten his expected meds and was under serious emotional stress. He referred me to the doctor. I asked the doctor, repeating the lack of 1 p.m. meds, the emotional stress, and oh, by the way, he likes to flip off clots when he’s this hypertensive. The doctor shrugged and said that if he were that way for months, they’d be unhappy, but a few hours weren’t going to hurt him, and anyways, they’re using a cardiac protocol.

Once my mom arrived, she asked, said exactly the same things I did and added in the bit about an aortic abdominal aneurysm. She got the same answer. They’re using a cardiac protocol, and his blood pressure being astronomically high was not a problem in the short term. It took her over an hour and finally using her Very Angry Nurse voice, saying “he is symptomatic, he has a headache, you will bring his blood pressure down now.”

He got shots, he got pills, and his blood pressure came down to something less likely to cause him to geyser blood into his abdominal cavity.

Still.

I realize, even as well read and knowledgeable a layperson as I am, that there are tons of things I don’t know about emergency medicine or treating a person with symptoms of an ischemic stroke. But, I’m at a complete loss.

What is this “cardiac protocol” both the doctor and the nurse referred to?

How is it possible that any cardiac protocol takes precedence in treating an elderly hypertensive man with neurological ischemic symptoms, an aortic abdominal aneurysm, and a past history of trans-ischemic attacks?

He has no history of heart attack, angina, or fibrillation. His one cardiac issue is the pacemaker installed because all the hypertension medications he takes brought his pulse down to less than 40 beats per minute, making it impossible for him to do much more than sit up. The pacemaker has been in place for over a year with no problems.

A google of “cardiac protocol” gives me nothing concrete. Neither the doctor nor the nurse explained exactly what the protocol was, what it was intended to do, or why they were applying it to my dad. It was a busy day at the ER, I know the staff often doesn’t have the time to explain every concept and detail, but this just didn’t make sense - not to me, and not to my mom, who is an RN with 40 years experience.

Help me out, guys.

2

I’m a student in the healthcare field and spend a lot of time in the hospital, so hopefully this is a little bit more helpful.

Hospitals have specific protocols for management of serious conditions; a stroke is one of them and has it’s own flowchart. The protocol is there so doctors follow a specific set of instructions and don’t forget anything important. This is guided by current medical knowledge and research as well as individual hospital policy. Think of it as a flowchart of what to do and when to do them.

A stroke if not treated quickly and correctly, can result in long term damage and disability. The CAT scan is used to see if the stroke is caused by a bleed in the brain. If there is blood, then medications that thin the blood cannot be used as they will make it worse and the patient will have to go to surgery.

If the stroke is caused by a clot, then the CT scan or MRI can also show evidence of this and blood thinning and clot-removing medications can be used. The ideal treatment time for both these variations is a matter of hours for best effect, so the medical staff were probably putting this as their #1 priority.

I don’t know enough in detail about management of the abdo aneurysm to give you any specific information on how hypertension might affect it, there is an increased risk of rupture with very high blood pressure. Maybe someone else can help with this.

3

Also, do you have a general practitioner? In Australia, GP’s are subsidised by the government and do a great deal of health care outside the hospital. A GP would be the best place to share your concerns with and get medically accurate information. I read a lot of medical forums just to understand what patient’s feel and often times there is a lot of misinformation going around. So take everything with a pinch of salt.

4

I’m not sure what ‘cardiac protocol’ refers to at the hospital in question. Regardless, I may be able shed a bit of light about the staff’s reluctance to lower his BP despite its high level.

In the setting of an acute stroke (from a clot, but not from a hemorrhage), it can actually be quite dangerous to lower the blood pressure. That’s because the area around the damaged part of the brain is typically in a very precarious state due to borderline blood flow into it. This is called the ischemic penumbra (2nd link).

The problem is made worse if there is swelling in the area around the stroke which is equivalent to saying there is high pressure locally in that area which tends to oppose the flow of blood into it. Further, if the BP has been high recently, the arteries to the brain tend to go into constriction to prevent that high blood pressure being transmitted to the brain. Should the blood pressure drop, the arteries do not immediately dilate to compensate. Rather, they stay constricted for a while. Of course, that means there will be a tendency for too little blood to get into the brain and, in particular, to the ischemic penumbra. The net effect, then, of lowering the BP in a stroke can be to increase the size and severity of the stroke. As a result, the current recommendation is to NOT the lower the BP in the setting of an acute stroke (from a clot) unless there is evidence that the high BP is causing real problems at that time such as angina, heart failure, bleeding in the brain, etc.

ETA: The above applies to TIAs as well.

5

KarlGauss, thank you. That is exactly the explanation I needed. It puts the ER staff’s behavior in perspective and makes it clear why they made the choices they did. I just wish they’d been more clear that it was an “ischemic protocol” and not a “cardiac protocol”. If they’re going to toss off medical jargon like that, it ought to at least be relevant to the patient at hand.

My guess is they finally agreed to treat his hypertension when they did because nearly six hours had passed since onset of symptoms, and his CT scan showed no evidence of a clot. It must be difficult, balancing the different issues a patient in crisis presents. Acute ischemia, chronic hypertension and an aortic abdominal aneurysm? Clearly, the ischemia takes precedence.

A question: are there no medications that would allow vaso-dilation without subsequent lowering of blood pressure? I know nitroglycerin is used for angina and dilates coronary arteries.

Another question: is there any indication that a spike in blood pressure during an ischemic event is a defensive response by the body to keep as much blood flow to the penumbra as possible? Or is it just happenstance? I’ve never seen my dad’s blood pressure spike that high, even when he was under similar emotional stress.

Again, thanks so much for the information. I’ll share it with my mom, as I know she was just as frustrated with the situation as I was.

6

I’m glad that you found that helpful!

Not really. Even nitro can lower the BP. Pretty well any medication that dilates arteries can, and usually does, lower the BP. The only exception (off the top of my head) is when someone’s heart is so far gone that dilating the arteries reduces the afterload on said heart to the point that it can actually pump blood more effectively with a subsequent increase in BP.

That is a super thought and it sure makes sense. But, like most teleological arguments, is hard to prove.

7

This is slightly off topic but isn’t there also a “glutamate cascade” that causes most of the damage? Can I assume that this is part of the penumbra? Thanks.

8

Nitro can raise ICP.

Nimodipine is generally thought of as a relatively cerebral selective calcium channel blocker, but even that has systemic effects. It is commonly given after a sub arachnoid hemorrhage to present secondary vasospasm and subsequent mortality/morbidity.

Spikes in blood pressure are common in disease states which raise ICP, such as intracerebral hemorrhages. This is known as the sympathoadrenal response. It generally results in nastiness and is important to control.

9

Yes. Cell death, neuronal or otherwise, is an active process. Cells that experience lack of blood supply (or lack of oxygen) don’t just passively 'roll over and die (so to speak) but, rather, undergo a dynamic chemical process, in part dependent on glutamate, which sets in motion a chain of events (calcium influx into the cell for example) that does kill them .

As you can see by my hand waving, this is not something about which I have a lot of knowledge, let alone understanding. So, take a peek at ecitotoxicity and apoptosis for infinitely more than I can offer.

ETA: Regarding your question, one hopes that this does not occur in the penumbra. In addition to maintaining adequate blood flow to that area by not lowering the BP too much, other ways (i.e. pharmacologic) of inhibiting the glutamate cascade and neuronal apoptosis are actively being sought.