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Discussion

Sedatives and Stroke

So I was just tested on CVA/IICP/LOC and other concepts.

I am confused by one of the questions and I need to know where I can find the answer because my book is not clear.

One of the questions was: a nurse is treating a stoke pt and would question which of the following medications?

Antihypertensive

sedative

and two more that I don't remember but would not have caused the patient any harm.

The answer was antihypertensive. Our text said treating HTN was contraversial and only if its above 185/110 for ischemic or it is a hemorrhagic stoke. So I can see how it might be possible to choose the antihypertensive drug, but there were no parameters that gave insight to any of this information. The reason I chose sedative is because you don't was to depress the CNS when you are assessing a stoke patient b/c it might not be an accurate score on the GCS or the NIH stroke scale. I thought I remember reading this somewhere but I can't find it now that I am going back through the book. Maybe it was a practice question that I did for the NCLEX on the evolve website? Can someone please clarify for me?

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    Reducing blood pressure with antihypertensives in an acute ischemic stroke decreases perfusion of brain tissue surrounding the area of initial insult. Reducing BP reduces the MAP, which can result in a larger area of ischemia. Sedatives are typically used with patients experiencing anxiety and agitation related to the stroke. It is not uncommon for stroke patients to receive benzos, antipsychotics, and antidepressants. As you can see, one class of medication has the potential to do much more and longer lasting harm than the other.

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    • Expert

    Moved to nursing student assistance

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    This is a tricky one, right? It illustrates the benefit of applying the "A(irway) B(reathing) C(irculation) -C-spine" rubric to help select the best answer. It is more commonly applied to emergency resuscitation, but it is applicable in this case because the HTN med directly impacts Circulation and the Sedative would only have an indirect potential impact upon Airway & Breathing.

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    • Expert

    This is where you go back to the answer....ABCD's (Airway, Breathing, Circulation, Disability) first.

    There is something called cerebral perfusion pressure which you are actually monitoring on a stroke (unless it is a bleed) but the purpose remains the same. Cerebral Perfusion Pressure (CPP) is defined as the difference between the Mean Arterial Pressure (MAP) and the Intracranial Pressure (ICP). CPP = MAP - ICP. This represents the pressure gradient driving cerebral blood flow (CBF) and hence oxygen and metabolite delivery.

    Which means the damaged brain has swelling and you need to maintain a certain brain pressure to be sure the brain is being perfused and the need to keep the blood vessels in the brain "full" to prevent Cerebral artery spasms which increase the area of insult.

    After brain injury cerebral blood flow may be lowered to the ischemic threshold. To prevent further neuronal death (the secondary brain injury), this flow of well oxygenated blood must be restored. There is no class I evidence for the optimum level of CPP, but 70-80mmHg is probably the critical threshold. Mortality increases approximately 20% for each 10mmHg loss of CPP. In those studies where CPP is maintained above 70mmHg, the reduction in mortality is as much as 35% for those with severe head injury.

    Cerebral Perfusion Pressure may be maintained by raising the Mean Arterial Pressure or by lowering the Intracranial Pressure. In practice ICP is usually controlled to within normal limits (

    Control of intracranial hypertension is discussed on the pages on

    intracranial pressure.

    There is substantial evidence now that early hypotension (BP

    Maintenance of an adequate MAP requires primarily a normovolemic patient. Control of other sites of hemorrhage has the highest priority (with oxygenation). These patients should NOT be kept 'dry' with fluid restriction, but maintained in zero balance. Further elevation of MAP, once normovolemia is achieved, is usually accomplished with norepinephrine, though dopamine may be used. There is little evidence to recommend any one agent over another.

    This is from a trauma site but it applies.

    TRAUMA.ORG : Neurotrauma : Cerebral Perfusion Pressure

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    Without any background information regarding the patient's BP you can't answer the question. On NCLEX a question like this would have the BP.

    My first instinct was sedative as you thought for the reason you thought. Many times, stroke patients have highly elevated BPs (hypertension is a risk factor for stroke) which need treatment. If there is a brain bleed acutely you must get the BP under control STAT. In the ED, we treat BP aggressively for patients getting TPA to get the systolic BP under 180 and diastolic under 100. Other posters were correct in bringing up permissive hypertension. If the patient has a BP of 162/84, their home anti-hypertensives may be held.

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