I'm a paramedic taking a class and am having a disagreement with my instructor. We were discussing nosebleeds, and she brought up hypertension as one of the causes. She says that you should stop the bleeding before attempting to drop the patient's pressure. I say it's better to bring the patient's pressure down before trying to stop the bleeding, or you risk causing a stroke. I'd rather my patient's nose bleed for a little bit than for him or her have a stroke. Thanks for your input.

Mike

Sorry, but I have to agree with your instructor. You undoubtedly have been taught the ABCs, but I'm going to review this for our readers. (Unfortunately, most people have not even taken a basic course in cardiopulmonary resuscitation.)

The ABCs are a fundamental concept in emergency medicine. A stands for airway, B for breathing, and C for circulation. The ABCs are usually discussed in the context of resuscitation. For example: You are in a restaurant. A man across the room suddenly stands, grabs his throat, staggers and drops to the floor. ABC indicates the appropriate order of intervention:

1. : One first inspects the airway. Is he breathing? Is there a lump of meat obstructing his airway? You can't give mouth-to-mouth if there's a lump of prime rib in the way. An appropriately trained individual could assess the situation and decide whether the victim needs a finger sweep (to pull something from the oral cavity) or a Heimlich maneuver (to dislodge something from the windpipe).
   
2. : Breathing. Our hero has determined that there's nothing obstructing the victim's airway. Is he breathing? Uncool to give mouth-to-mouth to someone who is breathing. If he's not breathing, an appropriately trained individual will direct someone to call for help ("You, call 911!") and then ...
   
3. : Circulation. Even before beginning mouth-to-mouth resuscitation, our hero checks for a pulse. If he's really on the ball, he's reporting all of this as he goes. ("He's not breathing and I can't feel a pulse! Call 911!") While someone else runs to a phone to call the paramedics, our hero begins mouth-to-mouth (breathing) and, if there's no pulse, chest compressions (circulation).
   

The ABCs also have pertinence to nosebleeds, but the considerations are different. Airway and breathing are inseparable: The caregiver must first determine if the patient is bleeding so vigorously that he is at risk of choking/suffocation. Anyone who has had a vigorous nosebleed knows that the blood will pour not only out the nostrils, but also down the back of the throat. If the patient has lost a great deal of blood, he may become unconscious or nearly so. In such circumstances, he will be unable to protect his airway and may choke on his own blood. This can lead to a respiratory arrest, or (almost as bad!) severe inflammation of the lungs (pneumonitis).

After determining that the patient is not at risk of choking on (or suffocating in) his own blood, the next consideration is circulation. In this context, the question is not "Is his heart still beating?" but "What can I do to limit his blood loss?" You are worried about the possibility of a stroke due to high blood pressure (which may or may not be present). Blood loss is a more pressing concern. Blood loss can lead to a heart attack or shock, either of which may end in death. If the blood is pouring out, you need to stop the bleeding, not futz around administering drugs to lower the blood pressure. (Indeed, in some circumstances this would be incorrect and hazardous.)

Your comment ("I'd rather my patient's nose bleed for a little bit ...") makes me wonder whether you have ever seen a rip-roaring nosebleed. I have seen nosebleeds of truly Biblical proportions. You have a particular case in mind -- a relatively minor nosebleed in a patient with very high blood pressure. In such a case, you might appropriately decide to treat the blood pressure problem first, but you must still ASSESS the extent of bleeding before proceeding to other problems. In other words, you can certainly imagine a situation in which your priorities are correct and your instructor's priorities are wrong, but even in such a situation, you must still address (think about) the bleeding before rearranging your priorities.