Nitro patches for strokes

[Pond Life]

Hi all,
We are doing a trial with nitro patches for stroke patients in parts of the UK. Blind study
Any services doing the same Stateside?If so I would be interested to hear your setup and research protocols
cheers
Pond Life

 

[Summit]

What is your treatment criteria? SBP > 200?

 

[Carlos Danger]

I thought the current thinking was not in favor of attempting to lower BP in the setting of stroke?

Interesting study, though.

 

[RocKetamine]

I thought the current thinking was not in favor of attempting to lower BP in the setting of stroke?

Interesting study, though.

Typically the consensus is to only treat if the SBP > 220 and/or DBP >120 or if the patient is tPA eligible for which they need to be below 185/120.

 

[NPO]

Typically the consensus is to only treat if the SBP > 220 and/or DBP >120 or if the patient is tPA eligible for which they need to be below 185/120.

I assume by "tPA eligible" you just mean meets field criteria for time and symptoms, since a bleed obviously woulsnt get tPA.

Also, nitro is probably not the best treatment for a bleed. How are you guys addressing patients with the possibility of a bleed?

 

[Summit]

Good discussion here:

http://www.medscape.org/viewarticle/554210

 

[Carlos Danger]

I don't keep up with this stuff as much as I'd like to, so I had forgotten about the BP threshold for TPA. Honestly, I thought TPA was going by the wayside anyway.

 

[Pond Life]

Inclusion

• Patients presenting to paramedics in context of 999 ambulance call for "stoke"
• Age 18 years or more
• FAST >2
• Time <4 hours of onset
• Sys BP >120
• Paramedic training in RIGHT-2 procedures, part of a participating ambulance station and will take to participating hospital
• Written or witnessed oral consent, or relative / paramedic proxy assent

Exclusion

• Patient in nursing home
• Blood Glucose ,2.5mmol/l
• GCS <8
• Witnessed seizure/fit at present
• now life expectancy <6 months
• Known to have taken a PDES inhibitor such as Sildenafil, in previous day before stroke
• Known hypersensitivity toTransderm Nitro patch
• Known sensitivity to DuoDERM hydrocolloid dressing

 

[cprted]

Pardon my ignorance, but what is the goal of the treatment? What is the proposed benefit of NTG in CVA patients?

 

[NPO]

Pardon my ignorance, but what is the goal of the treatment? What is the proposed benefit of NTG in CVA patients?

Vasodilation. Same as a coronary blockage, but in the brain.

 

[VFlutter]

Vasodilation. Same as a coronary blockage, but in the brain.

All I could find was this article from 1989 which suggests that 1mg of Sublingual nitroglycerin caused cerebral vasodilation. A much higher does than anyone would be delivering with nitro paste. It doesn't seem like a lot of evidence to support it and I would think the potential of dropping blood pressure and therefore cerebral perfusion would be higher.
http://stroke.ahajournals.org/content/20/12/1733.full.pdf

 

[cprted]

Vasodilation. Same as a coronary blockage, but in the brain.

SL doses of NTG aren't sufficient to cause coronary artery vasodilation. NTG is given to reduce afterload and thus reduces myocardial oxygen demand.

All I could find was this article from 1989 which suggests that 1mg of Sublingual nitroglycerin caused cerebral vasodilation. A much higher does than anyone would be delivering with nitro paste. It doesn't seem like a lot of evidence to support it and I would think the potential of dropping blood pressure and therefore cerebral perfusion would be higher.
http://stroke.ahajournals.org/content/20/12/1733.full.pdf

I found the same article. The only thing I could think of would be increasing venous dilation, increasing cerebral drainage, and thus lowering ICP.

 

[Aprz]

For increased ICP, I've seen Nicardipine (Cardene) used a bunch to maintain a systolic of about 140-150 mm Hg or MAP of 110-120 mm Hg out here while doing CCT transfers as an EMT (I was the gurney pusher/driver for a CCT RN). Since I was an EMT, I was of course absolutely clueless on exactly the benefit of lowering the blood pressure and never bothered to research it further. It is after all the opposite of what we are taught in EMS (high blood pressure is a compensatory mechanism and it should not be lowered, nitroglycerin is contraindicated in suspected increased ICP/head injuries/strokes). I've always assumed that even though we were taught that high blood pressure was compensatory that too high was bad. Like everything else in life, there needs to be a balance.

 

[Pond Life]

I thought you guys may appreciate the link to the study.
http://www.right-trial.org

 

[cprted]

I thought you guys may appreciate the link to the study.
http://www.right-trial.org

Thank you! Most appreciated.

 

[RocKetamine]

I assume by "tPA eligible" you just mean meets field criteria for time and symptoms, since a bleed obviously woulsnt get tPA.

Also, nitro is probably not the best treatment for a bleed. How are you guys addressing patients with the possibility of a bleed?

Yes, obviously tPA isn't used in bleeds. There is a tPA screening checklist that is widely used that will guide the ED physician as to whether the patient is eligible to receive treatment, with one of the exclusions being "Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)".

If the patient is a suspected stoke (ischemic or hemorrhagic) and is hypertensive above the cut off for tPA the BP is usually treated with Labetalol or Nicardipine.

 

[RocKetamine]

I don't keep up with this stuff as much as I'd like to, so I had forgotten about the BP threshold for TPA. Honestly, I thought TPA was going by the wayside anyway.

Depends on who you ask. It's not being pushed quite as hard as it was say 5 years ago but it's still widely considered the standard of care. AHA gives it a Class I level A recommendation, ACEP has it at a level B. In Houston they have a specialized ambulance that responds to suspected strokes with a CT scanner and if they're negative for a bleed tPA is started on scene.

 

[RocketMedic]

^ I think that this is the core of good stroke care; field imaging. Even something like temporal-window ultrasound (which is hardly definitive) would be a good step in the right direction, and if outlying places like Brazosport would get on the telemed/rapid CT/tPA train, I think we'd see meaningful improvement in stroke mortality.

 

[MonkeyArrow]

^ I think that this is the core of good stroke care; field imaging. Even something like temporal-window ultrasound (which is hardly definitive) would be a good step in the right direction, and if outlying places like Brazosport would get on the telemed/rapid CT/tPA train, I think we'd see meaningful improvement in stroke mortality.

That's doubtful judging by the paradigm shift away from tPA in general.