nimodipine for intraparenchymal bleed or only for subarachnoid?

[Painter1]

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so all the texts say give nimodipine for non-traumatic subarachnoid. what about in a good'ole intraparenchymal bleed?

 

[roja]

We don't really use Ca channel blockers much. We tend to use labetalol for bleeds. In theory, you can use Nitroprusside but haven't seen that done in 5 years (pain to hang)

 

[EMCC]

so all the texts say give nimodipine for non-traumatic subarachnoid. what about in a good'ole intraparenchymal bleed?

Remember the reasoning behind giving Nimotop (nimodipine)...

It is to prevent delayed vasospasm and resultant (recurrent) bleeding and/or neuro deficits. That's why it is given w/ SAH. Intraparenchymal bleeds are not due to aneursymal bleeding, nor are they at risk for vasospasm.

IPH is usually due to tumor/trauma/AVM, etc, etc, etc.

Would you be wrong to give Nimotop to IPH? No, but it isn't going to help, and you are more likely to see the side effects "pop up" as well.

Hope that helps

 

[overthebars]

So alot of lit says Labetolol (as above) or nicarpidine for BP control after a CVA. When is nicarpidine used? If +Cocaine toxicity and an IPH?

 

[EMCC]

So alot of lit says Labetolol (as above) or nicarpidine for BP control after a CVA. When is nicarpidine used? If +Cocaine toxicity and an IPH?

Depends on who you talk to... Cardene is a phenomenal (spelling?) drug when it comes to BP control. Labetolol is a phenomenal drug when it comes to BP control. Nitroprusside is a great drug when it comes to BP control (but now 2nd line behind the 1st 2).

All 3 are very good. The benefits of Cardene are easy dosing (5, 10, or 15 mg drip) and easy "on/off". The benefits of Labetolol are the beta blockade and is in almost every accudose cart. So, you can't go wrong with starting with either, and then using the other if you max out/can't get good BP control. Plus, good luck getting a Cardene drip on a patient on a tele floor.

As for the cocaine + beta blockers "mantra.." Many new studies are coming out showing that beta blockers do NOT cause unopposed alpha excitation. It is true that studies of coronary arteries in healthy subjects injected with cocaine (how did that get IRB approval??!) do get elevated BPs. Systemic effects, however, have not been appreciably demonstrated. So, while most EM docs still avoid beta blockers w/ cocaine, you probably won't notice any problems if you do end up using beta blockers. Personally, I try to avoid them, but there have been quite a few CP patients I have admitted (on Lopressor) that ended up being cocaine+ on their UDS. Shockingly, there were no adverse effects.

Granted, my sample size is extremely small, but the more recent literature seems to bear out the lack of "runaway" alpha excitation with beta blockers...