[NREMT-P/RN]

I am tossing this out for all the great neuro folks out there -

All comments are WELCOME.

Rescued a patient from a small ED into tertiary care that had been placed on a nitroGLYCERIN gtt at 5 mcg/min for SBP control (Presented to ED with 240/130, down to 160/90 on our arrival) in the presence of a confirmed acute (2 hours post symptom onset) ICH. Parietal area bleed > 5cm with ventricle congestion, remained midline on initial CT (but, I suspected that would change soon). Patient was initially alert & able to maintain own airway, pronounced unilateral deficit, PERLA initially, best GCS 13.

ED doc insisted that neuro MD at the receiving facility approved this clinical course (the nitro gtt). I thought my eyes would pop out of my head when I saw it hanging. I asked the ED doc 4 times if he was sure that he wanted to continue the ntg gtt. He was committed. Pt had also been given a couple of bolus doses of labetalol. My partner and I decided to get out as quicky as we could (still took about 20 min to get out of referring facility), then the patient was OURS. Pt had been on ntg gtt for over an hour at that point.

Anyway, the minute that we got the pt to the a/c and their staff turned to go, we turned that ntg gtt OFF. Well, the flight was not uneventful (but mercifully short). Ultimately, the patient had a HYPOtensive (90/50) episode lasting < 5 minutes, rebounded into HYPERtension (170/90) had a brady episode (imagine that!), RR dropped to 6 and required RSI/ETT placement inflight. HR rebounded initially then brady again and into PEA - exited a/c in full arrest. I'm aware that the clinical course may not have been impacted as this was a wicked bad bleed, but....

Anyway, the whole thing was rotten.

??? Are there any neuro folks out there currently using nitro for SBP control in ICH???

I'm confident that I know what I know - but, just in case I've not kept up cutting edge treatment and I'm wrong - I'm pleading for any insight that all the great neuro folks out there could share with me.

Anyone have any comments that they can share on this case? Thanks in advance.

Practice SAFE!

[nrsang97]

We DON'T use nitro or nipride because the SBP drops TOO FAST! If a pt comes up to us from the ER or PACU with nipride or Nitro we change them fast to Nicardipine.

I had to assist with EVD placement in the ER a few months ago and the pt had nitro and nipride at MAX doses and we still COULD NOT ger her SBP <240. Also while in the ER we gave labatelol and pt went brady (suprise suprise) but HR came back up. EVD placed in the ER and brought up to the floor. We changed to nicardipine and pressures were much better shortly after starting the gtt. I really don't think that changed this pt outcome. She was already intubated and left us trached and pegged.

Our unit is the only one allowed to use nicardipine I believe. It isn't even in the collegue guardian pump yet.