The drug induced ICH

[VentMonkey]

His MAP is 160 if I did the math correctly, that's far too high. I can't remember where I read it but it associated severe hypertension with worse M&M similarly to hypotension. I believe the "highest" you want to see is 130mmHg so I think it would be prudent with this guy but you also don't want a huge drastic drop in his pressure as well.

The two obvious choices are either esmolol or labetalol. Both have a quick onset but esmolol is going to be faster however labetalol is going to have a longer effect. I don't think you'd be wrong with either, the faster onset of esmolol might be beneficial for this guy although I believe labetalol was shown to be more effective during intubation for patients with increased ICP.

Ultimately this dude needs his head opened up, quickly. Even then he likely will not have any sort of quality of life if he does survive this.


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Agreed. All we carry on the CCT side is Labetolol, so he probably would have gotten 10 mg IVP, had again, I had my nurse with me; it's what they gave him at the ED, and it dropped his systolic with sufficient efficacy.

There are thresholds, but I can't currently recall. I know many head bleeds (SAH's) once stabilized, end up on Nipride to keep their systolic ~140 mmHg.

Again, I am still learning myself, and by no means am I an experienced ICU clinician, so if anyone of the many that are on this forum would like to, please, feel free to expand my (our) knowledge.

 

[Handsome Robb]

I'd be interested in @Remi's take on treating the BP. Also any of the various Docs we have on here.


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[VentMonkey]

I'd be interested in @Remi's take on treating the BP. Also any of the various Docs we have on here.


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Likewise...@Chase?

 

[Summit]

I'd use NIcardipine, but I am not sure how eager I am about sacrificing time to bring the pressure down. Your transport times are short. Almost like intubation in this scenario, it is a secondary concern. This is a load and go.

 

[VentMonkey]

I'd use NIcardipine, but I am not sure how eager I am about sacrificing time to bring the pressure down. Your transport times are short. Almost like intubation in this scenario, it is a secondary concern. This is a load and go.

As it was. I think scene time from patient to en route was somewhere ~5-7 minute ballpark. I wasn't too concerned with his airway as he did a fine job of protecting it himself; he even let out a yawn after I stopped the sz with the Versed push.

I was always under the impression Nicardipine or the like were more long term. Do you carry it in your tool kit, and if so, is it an IVP med?

Our doc seems to favor Labetolol, and my understanding it's one of the safer antihypertensives to administer in the prehospital setting. Assuming of course, they're hemodynamically stable.

 

[Summit]

As it was. I think scene time from patient to en route was somewhere ~5-7 minute ballpark. I wasn't too concerned with his airway as he did a fine job of protecting it himself; he even let out a yawn after I stopped the sz with the Versed push.

I was always under the impression Nicardipine or the like were more long term. Do you carry it in your tool kit, and if so, is it an IVP med?

Our doc seems to favor Labetolol, and my understanding it's one of the safer antihypertensives to administer in the prehospital setting. Assuming of course, they're hemodynamically stable.

Nitroprusside I consider a little scary because of the delays in onset and the length of action, you can end up with provider induced blood pressure oscilllation unless you are very well practiced titrating it. We stopped using it in ICU in favor of Cardene because Cardene is fast, powerful, and great for heart and brain patients.

For this scenario, the other problem with nitroprusside is that it is a cerebral vasodilator and causes increased ICP relative to the resulting BP. Nicardipine does not have this problem.

Since we don't want super rapid drops in pressure (its not just stimulation causing that high pressure, it is actually helping drive your CPP even though it harmful to be so high), I think nicardipine is quite appropriate for the ICH patient. And you could drop a pressure hard and fast if desired (not desired). We have it available as a frontline BP med post CABG for this exact reason with nitroglycerine drip as the second line.

Similar mechanism, Cardene superior to Brevibloc
https://www.ncbi.nlm.nih.gov/pubmed/25296247

But it seems that both beta blockers and nicardipine are acceptable. This is a good discussion:
http://www.medscape.org/viewarticle/528848

All that said, this is my ICU outlook. I have my hands tied prehospital.

 

[VentMonkey]

Nitroprusside I consider a little scary because of the delays in onset and the length of action, you can end up with provider induced blood pressure oscilllation unless you are very well practiced titrating it. We stopped using it in ICU in favor of Cardene because Cardene is fast, powerful, and great for heart and brain patients.

For this scenario, the other problem with nitroprusside is that it is a cerebral vasodilator and causes increased ICP relative to the resulting BP. Nicardipine does not have this problem.

Since we don't want super rapid drops in pressure (its not just stimulation causing that high pressure, it is actually helping drive your CPP even though it harmful to be so high), I think nicardipine is quite appropriate for the ICH patient. And you could drop a pressure hard and fast if desired (not desired). We have it available as a frontline BP med post CABG for this exact reason with nitroglycerine drip as the second line.

Similar mechanism, Cardene superior to Brevibloc
https://www.ncbi.nlm.nih.gov/pubmed/25296247

But it seems that both beta blockers and nicardipine are acceptable. This is a good discussion:
http://www.medscape.org/viewarticle/528848

All that said, this is my ICU outlook. I have my hands tied prehospital.

Cool, thanks. I'm really digging where this thread has gone thus far...and learning a lot.

 

[TXpeds16]

With a longer transport I would have considered antihypertensives, however that would be something I would want to contact med control about. My logic may be completely flawed, but i've always viewed giving antihypertensives to stroke patients in the field similarly to intubating an asthmatic. You are taking away the bodies physiologic response that is trying to maintain CPP. Does he ultimately need some form of antihypertensive? Absolutely. That is something i would want to titrate to affect though with cardene or the like. At my previous service we carried labetalol, and bolusing that in a stroke patient isnt something ive been overly comfortable with or accepting of.

Having said that, this guys MAP is 160. Minimum CPP to maintain adequate perfusion is ~60. So unless this guys ICP is 100, you should be just fine dropping his pressure at a reasonable rate.

 

[VentMonkey]

With a longer transport I would have considered antihypertensives, however that would be something I would want to contact med control about. My logic may be completely flawed, but i've always viewed giving antihypertensives to stroke patients in the field similarly to intubating an asthmatic. You are taking away the bodies physiologic response that is trying to maintain CPP. Does he ultimately need some form of antihypertensive? Absolutely. That is something i would want to titrate to affect though with cardene or the like. At my previous service we carried labetalol, and bolusing that in a stroke patient isnt something ive been overly comfortable with or accepting of.

http://stroke.ahajournals.org/content/40/6/2251

This is a somewhat outdated AHA article, but one of the quicker reads I could find.

Having said that, this guys MAP is 160. Minimum CPP to maintain adequate perfusion is ~60. So unless this guys ICP is 100, you should be just fine dropping his pressure at a reasonable rate.[/QUOTE]
The ICU I did clinicals at focused all of their attention on decreasing stimulus, with a CPP target goal of ~70 mmHg, and a watchful eye before moving on to asking for orders before the intensivists made their rounds.

I can't really say I disagree with you as I am not 100% confident with neuro myself, but again, enjoy seeing how, what, and why it is others are practicing/ being taught.

 

[Carlos Danger]

Lowering pressure on these patients is tricky. There seems to be little consensus on how much it should be lowered, or whether it even should be. The only thing that seems universally agreed on is that if you are going to lower it, do it slowly and do not try to normalize it. It is high for a reason.

Personally, the drug I would be most comfortable using is nicardipine, for the reasons already stated. As Summit said, it is much easier to use accurately, at least unless you are really familiar with using the nitrates in these patients.

With a transport as short as the one in this scenario, I would not attempt to lower this pressure at all, for the same reasons I wouldn't intubate.

If I had a longer transport (say, >30 min), then I would defer to my protocols or OLMC, because of the lack of consensus and lack of my own expertise with this stuff. If I were told to lower his BP or for some reason felt it was really the right thing to do, I'd probably first intubate and sedate gently, and see where he's at then, and at that point, assuming I don't have a bag of cardene and an IV pump, start giving very small boluses labetolol every 5 minutes until I reached a target MAP of 10%, definitely no more than 20% lower than where he was when I first found him.

 

[Tigger]

I can recall treating a similar patient a few years ago. He began to vomit, which necessitated an RSI. Things went downhill after that, his pressure went from 190/120 to 270/140 once his (difficult) airway was secured. He was kept paralyzed so who knows if he seized after that. Our flight crew uses Cardene for these patients as does the ED and in my very limited experience with it during clinicals, it seems like a great drug for this sort of patient.

 

[VentMonkey]

I can recall treating a similar patient a few years ago. He began to vomit, which necessitated an RSI. Things went downhill after that, his pressure went from 190/120 to 270/140 once his (difficult) airway was secured. He was kept paralyzed so who knows if he seized after that. Our flight crew uses Cardene for these patients as does the ED and in my very limited experience with it during clinicals, it seems like a great drug for this sort of patient.

http://link.springer.com/article/10.1007/s12028-012-9782-1

 

[VentMonkey]

I just came across this, and found it relavent to this scenario:

http://www.airmedicaljournal.com/article/S1067-991X(16)30066-9/abstract?showall=true=

 

[MackTheKnife]

Sux sucks? LOL! It used to be Numéro uno back in the day.

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[MackTheKnife]

Transtentorial? You obviously paid attention in school!

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[VFlutter]

Blood pressure management in a neuro patient is extremely complex. Take a walk through the Neuro ICU and you will see patients on a variety of vasoactive drips to maintain a very narrow CPP window. In the prehopsital setting without ICP monitoring and defined pathology you do the best you can for the patient but it will always be a balancing act. Having said that per my protocols it is SBP<160 for Hemorrhagic stroke, and SBP<140 for SAH.

I prefer Cardene drips as others have mentioned but I also believe it has shown benefit in ICH/SAH patients due to reducing cerebral vasospasm.

I actually just had a patient with a massive SAH d/t ruptured aneurysm however they were profoundly hypotensive on my arrival, which is even more ominous than hypertension. They were actively being hyperventilated and likely herniating. In hindsight I probably should have been more aggressive and started pressors but it was a few minute flight and was busy with other drips. Interestingly, giving TXA, which I haven't done for ICH/SAH before.