# Head Trauma - Contraindication for Nitro?



## AnthonyM83 (Oct 22, 2010)

I was wondering widespread the nitroglycerin (for CP) contraindication of "head trauma" was. I've seen it plenty of times....yet I've also seen it not mentioned plenty of times.

Trying to get a sense of how often it gets left out due to how rare head traumas with chest pain were versus it just not really being a worrisome contraindication. I only know of one instance where it was given to a head trauma patient (medic was reasoning that injury might have led to MI)...patient condition significantly worsened...but no way to know how much (if any) nitro contributed.


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## Handsome Robb (Oct 22, 2010)

Are you asking why its contraindicated? Or are you asking how many people overlook the fact its contraindicated in a Pt. with CP and Head Trauma?


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## Shishkabob (Oct 22, 2010)

My only contraindication for nitro is hypotension.  


Though I'm really wondering a time that I'd have chest pain that made me think MI (as opposed to chest trauma) ALONG with a head injury with possible IICP.


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## AnthonyM83 (Oct 22, 2010)

CLARIFICATION: Trying to see how many people were taught that head trauma is a contraindication for nitro?
(Thanks NVRob)

We teach it in our EMT program for assisting with perscribed nitro, but someone brought up that a number of sources don't even list it as a contraindication. Just seeing how widespread it is...


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## CAO (Oct 22, 2010)

Somebody correct me if I'm wrong, but doesn't it have to do with the vasodilation?

If the head trauma resulted in a hematoma, the opening the vessels that are feeding it aren't exactly going to help.

It would to an increase of ICP, which would lead to a slowing of the heart rate.  Open vessels without the flow to keep up perfusion: now the poor guy's in shock.  That's probably not going to help with the chest pain, either.

Edit: Well, dang.  Missed the post explaining what was being asked exactly.

Yes, I've been taught, but not the exact reasons behind it.  The above was what I always thought.

The only time I could think of this coming up is somebody falling from sudden pain, and somebody was able to witness that the patient complained of the pain before the fall.


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## Aidey (Oct 22, 2010)

MVA is a possible scenario to, with the MI causing the MVA.


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## Shishkabob (Oct 22, 2010)

Aidey said:


> MVA is a possible scenario to, with the MI causing the MVA.



Ah, point noted.


Really, if they have a head injury with possible IICP, and are combative (as many of my head injuries have been), ruling in /out an MI isn't high on my priorities, especially since, say in an MVC, the same thing that caused the head injury could also cause a cardiac contusion, which can show as ST-elevation, chest pain, shortness of breath and *gasp* diaphoresis... the hallmarks of an MI.


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## Cawolf86 (Oct 22, 2010)

LA County in CA is taught head trauma is a contraindication for nitro.

Same reason - vasodilation leading to an increase in ICP.


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## Handsome Robb (Oct 22, 2010)

Well in that case, yes, I was taught head trauma is a contraindication of NTG.


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## 18G (Oct 22, 2010)

With a head injury (TBI) it is important to prevent a secondary insult from hypoxia and hypotension. Both increase mortality dramatically in the TBI patient. Giving NTG can produce both of these secondary insults. 

Giving NTG to a head inured patient could be lethal if it produces hypotension. Secondly, with the vasodilatory effect on cerebral vessels I would make a safe bet to say it would worsen swelling and ICP and produce cerebral hypoxia as it would lower the MAP below the point needed to over come the ICP and to maintain cerebral perfusion. 

I have seen head injury listed as a contraindication for NTG.

EDIT:
And just to add with TBI...hypertension is a protective mechanism (auto-regulation) in TBI with ICP to ensure blood flow to the brain. Giving NTG will oppose and perhaps knock out that compensatory mechanism.


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## Aprz (Oct 22, 2010)

I didn't learn that in my EMT program, but it makes sense.


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## rhan101277 (Oct 22, 2010)

Its a cerebral perfusion pressure issue.  In head trauma patients it is critical to maintain systolic BP at 90mmHG.  There is a formula used to come up with that number.  If it drops below that then survival from such an injury is unlikely.

Giving nitro can cause a blood pressure change as well as vasodilation which has already been mentioned.


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## 18G (Oct 22, 2010)

> In head trauma patients it is critical to maintain systolic BP at 90mmHG.



I'm sure there are different recommendations and guidelines but I've always read that a SBP of 100-110 is the target minimum since it is that pressure which will maintain a MAP of at least 60 which is necessary for cerebral blood flow to overcome the ICP.


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## rhan101277 (Oct 22, 2010)

18G said:


> I'm sure there are different recommendations and guidelines but I've always read that a SBP of 100-110 is the target minimum since it is that pressure which will maintain a MAP of at least 60 which is necessary for cerebral blood flow to overcome the ICP.



Yeah maybe it is around that area, 90mmHg is permissive hypotension.


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## EMS/LEO505 (Oct 22, 2010)

We were taught that Nitro is a contraindication for head trauma...all youre gonna do is make the blood bleed faster lol


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## VirginiaEMT (Oct 22, 2010)

rhan101277 said:


> Yeah maybe it is around that area, 90mmHg is permissive hypotension.



It is 100 mmHg here in my area. Another contraindication is male enhancement drugs.


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## andrey (Oct 23, 2010)

If you will appoint Nitroglycerine,a hypostasis of apatient,s  brain waits for you^_^
There will be problems with breath,сonsciousness и And the law


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## bryncvp (Oct 23, 2010)

In RI, nitro is contraindicated for anyone with a SBP under 90. For Basics, it is a med control med for the pt's nitro, for ALS, its a standing order for anyone with SBP over 90 with an IV established and a SBP over 150 without IV and it does not need to be the pt's own. As far as I know, a head injury was not discussed as a contraindication.

Correct me if I am wrong...and I am sure there are examples that fall beyond this example....but if there was a head injury, wouldnt the HR slow and decrease the BP anyway below the 90 causing the pt to be hypotensive therefore making nitro contraindicated? Again, I know there are exceptions, but wouldnt this be the general rule?


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## 18G (Oct 24, 2010)

Hypotension in the presence of a head injury is an atypical finding. Most of these patients will be normotensive or hypertensive. The bradycardia that is sometimes present with ICP will not lower the BP until the very end and is a terminal sign. 

The bradycardia in head injuries is caused by a parasympathetic response to the aggressive sympathetic attempt to increase blood pressure and increase cerebral perfusion. The baroceptors sense the increased blood pressure induced by the parasympathetic system and signals via the vagus nerve to decrease heart rate to try and compensate.


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## 18G (Oct 24, 2010)

18G said:


> The baroceptors sense the increased blood pressure induced by the parasympathetic system and signals via the vagus nerve to decrease heart rate to try and compensate.



Correction... should read, "induced by the SYMPATHETIC system".


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## andrey (Oct 25, 2010)

On any way...we can get тrunk of a brain,s inclination.


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