# Analgesia during CVA/Stroke



## the_negro_puppy (Dec 5, 2011)

How do you guys manage pain in acute CVA stroke pt's?

Recently had a 50 y.o F pt with severe 9/10 headache to R) temporal region, complete L) side hemiplegia, slurred speech, BP220/120, GCS14 with emesis and incontinence during bed transfer at hospital.

I ended up giving 2.5mg IV morphine with little effect on the pain, but did not want to give more as I didn't want to further alter the patient's conscious state during the 40 minute tx. With only paracetamol and methoxyflurane available we had nothing else for pain relief. She ended up having a significant bleed in her basal ganglia.

What drugs do you guys use in situations like this? what is your opinion of analgesia during CVA's? Would you have given more analgesia?


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## Brandon O (Dec 5, 2011)

Interesting issue. Just to be clear, I'm curious why in particular you didn't want to alter his mental status?


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## the_negro_puppy (Dec 5, 2011)

Brandon Oto said:


> Interesting issue. Just to be clear, I'm curious why in particular you didn't want to alter his mental status?



* it was a female/ she

This pt was already GCS14 E3V5M6, finding it very difficutl to speak, answer questions and kept 'falling asleep' 'snoring' but could be instantly roused. Given she had already consumed alcohol, her conscious state was the main indicator I was using to monitor the 'progression' of her CVA. My rationale was that given her larger does of morphine would make it more difficult to assess her true mental status/GCS and differentiate whether any reduction was due to therapeutic effects of MS or progression of her CVA.

I dont like to see people in pain but in this circumstance I felt it was more important to carefully monitor her mental and respiratory status, to be prepared for any ventilation or airway issues should she deteriorate.

Im just curious as to how others treat severe headache due to CVA.


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## MSDeltaFlt (Dec 6, 2011)

With those VS?  Labetalol and fentanyl.


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## systemet (Dec 6, 2011)

MSDeltaFlt said:


> With those VS?  Labetalol and fentanyl.



Would you be comfortable giving the labetalol without a CT?  I realise the MAP here is quite high, but do we know if the patient has pre-existing HTN, or if this is ischemic vs. hemorrhagic?

I'm not challenging you -- I've never been given the autonomy to give labetalol to treat HTN in neurologic syndromes, I'm just wondering what the best practices are?


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## Melclin (Dec 6, 2011)

Stemetil or maxolon, preferably the former, is something to consider. Maybe a little fluid if they're a bit volume depleted and its appropriate given the scenario and vitals etc.

If you're worried about conscious state, with a 40 min transport, fentanyl will be wearing off pretty well by then. You're lucky you have panadol :glare:

I know this sort of depends on what your local docs believe, but if you've got a good neuro exam and GCS, titrate some pain relief, you can still observe drops in conscious state. Its a bit like a multi trauma pt with a head injury. You need to treat their pain. Doing so doesn't really stop you from observing decline in conscious state. You will still easily be able to observe a conscious state drop requiring a tube, which is the point I suppose. 
EDIT: I just read a bit more of the scenario. I def get where you're coming from. But I stand by what I've said.  

But if you carefully titrate, it shouldn't be that much of an issue, pain is a pretty good opiate antagonist.


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## Shishkabob (Dec 6, 2011)

systemet said:


> Would you be comfortable giving the labetalol without a CT?  I realise the MAP here is quite high, but do we know if the patient has pre-existing HTN, or if this is ischemic vs. hemorrhagic?
> 
> I'm not challenging you -- I've never been given the autonomy to give labetalol to treat HTN in neurologic syndromes, I'm just wondering what the best practices are?



When is had lebetalol and Metoprolol, it was primarily for chest pain and neurological symptoms.


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## MSDeltaFlt (Dec 6, 2011)

systemet said:


> Would you be comfortable giving the labetalol without a CT?  I realise the MAP here is quite high, but do we know if the patient has pre-existing HTN, or if this is ischemic vs. hemorrhagic?
> 
> I'm not challenging you -- I've never been given the autonomy to give labetalol to treat HTN in neurologic syndromes, I'm just wondering what the best practices are?



That's where good history taking comes in to play.  I don't have that kind of autonomy either. It is a Med control order only. If there is a bad cell phone connection and I can't get Med Control, I can't give it at all.  That protocol is that new for us.  But I have given That in the air plenty of times.  I have no problem, ischemic or hemorrhagic, in giving labetalol.  Just don't drop the MAP too much too soon. 20mg isn't that much in reality.  Especially When given over 2-5 min.


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## Rettsani (Dec 6, 2011)

The drug labetalol it lowers the blood pressure? or?
How far can you lower blood pressure in stroke ?

We reduce blood pressure in stroke patients rarely. 

Here is taught that the blood pressure reduction the marginal zone of the stroke harm, because the blood flow is reduced further.  :unsure:


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## MSDeltaFlt (Dec 6, 2011)

Rettsani said:


> The drug labetalol it lowers the blood pressure? or?
> How far can you lower blood pressure in stroke ?
> 
> We reduce blood pressure in stroke patients rarely.
> ...



You don't want to decrease the MAP by more than 10%.  But it's like giving NTG in ischemic chest pain. Treat the the problem you treat the symptom.


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## Rettsani (Dec 6, 2011)

MSDeltaFlt said:


> You don't want to decrease the MAP by more than 10%.  But it's like giving NTG in ischemic chest pain. Treat the the problem you treat the symptom.



I does not know the effect on the heart is not in my opinion comparable to the effect on the brain.

Nitro reduces the preload of the heart and the oxygen consumption.
The decrease in preload leads to improved blood flow and a decrease of capillary pressure.

I think exactly this effect may not be useful for the brain. Because the blood flow decreases so in the damaged area by the vasodilation. A blood pressure lowering can in my opinion, lead to an increase in damage because the oxygen exchange in the capillaries decreases.


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## MSDeltaFlt (Dec 6, 2011)

Rettsani said:


> I does not know the effect on the heart is not in my opinion comparable to the effect on the brain.
> 
> Nitro reduces the preload of the heart and the oxygen consumption.
> The decrease in preload leads to improved blood flow and a decrease of capillary pressure.
> ...



You're missing the point.  I'm not saying they have the same mechanism of action. What I'm saying is that NTG is used to treat what is causing the pain in the first place.  So, not unlike NTG, lebatalol treats what is causing the stroke like symptoms. So, by giving that, you treat the pain as well.  Giving analgesia and treating pain are not necessarily the same thing. Treating pain includes more than just analgesia alone.

That's my argument.


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## Rettsani (Dec 6, 2011)

@MSDeltaFlt
That is clear.
The argument I can accept.

I just hope my way of thinking does not make me to a bad EMT. :unsure:


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## medicsb (Dec 6, 2011)

Brandon Oto said:


> Interesting issue. Just to be clear, I'm curious why in particular you didn't want to alter his mental status?



One does want to be careful how much of a narcotic is given.  One of the most important indicators for cutting a patients head open (depending on where the hematomato is located) is a decreasing level of consciousness.


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## Dwindlin (Dec 6, 2011)

Don't know that I would be quick to give a narcotic period.  Headaches that accompany CVA are often times migrainous, which can be worsened by narcotics.  Outside of skull fractures and pain from cancer narcotics are rarely indicated for head pain.


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## MSDeltaFlt (Dec 6, 2011)

Dwindlin said:


> Don't know that I would be quick to give a narcotic period.  Headaches that accompany CVA are often times migrainous, which can be worsened by narcotics.  Outside of skull fractures and pain from cancer narcotics are rarely indicated for head pain.



Is that specifically written in your protocols?


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## the_negro_puppy (Dec 6, 2011)

Dwindlin said:


> Don't know that I would be quick to give a narcotic period.  Headaches that accompany CVA are often times migrainous, which can be worsened by narcotics.  Outside of skull fractures and pain from cancer narcotics are rarely indicated for head pain.





MSDeltaFlt said:


> Is that specifically written in your protocols?



Thats the thing we are permitted to use narcotics for migraines etc as part of our protocols. We obviously don't go handing out Morphine like candy to everyone with a headache, but someone with 9/10 pain (who was actually bleeding) into their brain deserves something at least. Anyone have anyone have any experiences as to what they do at hospital/ER for analgesia in CVA patients?


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## usalsfyre (Dec 6, 2011)

medicsb said:


> hematomato


Off topic, but is this not one of the better autocorrect fails ever?


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## MSDeltaFlt (Dec 7, 2011)

the_negro_puppy said:


> Thats the thing we are permitted to use narcotics for migraines etc as part of our protocols. We obviously don't go handing out Morphine like candy to everyone with a headache, but someone with 9/10 pain (who was actually bleeding) into their brain deserves something at least. Anyone have anyone have any experiences as to what they do at hospital/ER for analgesia in CVA patients?



Exactly my point.  Thank you.


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## Dwindlin (Dec 7, 2011)

MSDeltaFlt said:


> Is that specifically written in your protocols?



Not quite sure what you're asking here.



the_negro_puppy said:


> Thats the thing we are permitted to use narcotics for migraines etc as part of our protocols. We obviously don't go handing out Morphine like candy to everyone with a headache, but someone with 9/10 pain (who was actually bleeding) into their brain deserves something at least. Anyone have anyone have any experiences as to what they do at hospital/ER for analgesia in CVA patients?



Honestly after a closer lit. search it seems pretty contested.  I've found many that advocate narcs, and just as many that do not (one interesting article recommending IV Tylenol actually).  Fortunately one of my residents on the psychiatry service is an off-service neurology resident, so I'll bug him tomorrow after rounds.


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## KellyBracket (Dec 7, 2011)

A lot of aspects to this case, but I'll only focus on 1.

This patient presented as a likely CVA with a BP of 220/120. That's an interesting BP in this context.

If you look at the AHA guidelines for ischemic stroke  (which you could not have ascertained in the field), lowering the BP is only indicated for a SBP above 220 or DBP above 120. Below that, you have to worry about iatrogenic harm from lowering the cerebral perfusion pressure.

With that in mind, I would avoid making any decisions w/o med con about treating HTN in the field. However, treating pain and nausea are very appropriate.

It's a little bit different when you find out it's hemorrhagic; I'll leave that controversy alone for now!


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## Fish (Dec 7, 2011)

usalsfyre said:


> Off topic, but is this not one of the better autocorrect fails ever?



Haha


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## Fish (Dec 7, 2011)

Not sure if this question has been asked to Negro puppy, but has your service run into problems with a Narcotic like Ms being given to a CVA with unknown origin seeing as out of all of the IV narcotics avail it is one of the most dialating? Do you have Fent. or something that have lower effects on vessels?


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