Atropine & ICP

[Paramark14]

Does anyone have data / comments on the use of atropine and risk of increasing ICP, especially in CVA pts. who become bradycardic and HPT?

Mark
EMTP
Indiana

[MM187]

Don't know how current my info is. My books show that there is "No Contraindications in the emergency setting" Atropine does not increase the the strength of cardiac contractions, but may increase myocardial oxygen demand.

[Paramark14]

Thanks for the reply. Let me be a little more specific on why I ask. I had a interfacility transport of a 70 y/o w/m who had suffered a CVA earlier that day at home.CT indicated a left occipital bleed. Pt. had right side paralysis, unresponsive except to pain, SaO2 was 98%, v/s were fairly normal. He had a TKO NS and a Dilantin drip, O2 @ 4 lpm by NC. Shortly after transport began he had a grand-mal seizure lasting approx. 30-45 seconds. MC ordered 5 mg valium IV. I gave the valium and and no more seizure activity was seen. About ten minutes later his heart rate dropped to a s-brady of 44 and the BP dipped to 78/30, still responsive to pain. I switched the O2 to a NRB at 15 lpm and gave a 250 cc bolus. There was no change in v/s. I called the receiving MC and requested either a mg of atropine or if they wanted me to attempt pacing (in my opinion this was a symptomatic bradycardia), both were denied. The heart rate continued to drop but stabilized at around 38-40, B/P 72/36. Transport time was 45 minutes. Since the pt. was a direct admit to neuro. ICU and we had another call, I did'nt have a chance to talk to MC doc. The pt. has survived with some permanent R side paralysis. Just curious if anyone has any comments / suggestions. If you increase HR you decrease filling time and thus the B/P will drop more, on the other hand if you do anything to increase the B/P (ie; fluid challenge, inotropics, etc) you'll risk increasing the cerebral bleed. To me its a catch-22. Thanks.

Mark
EMTP
EMTP
Indiana

[This message has been edited by Paramark14 (edited May 02, 2000).]

[This message has been edited by Paramark14 (edited May 02, 2000).]

[MM187]

I understand your situation.. What did the receiving hospital do to stabilize this pt., and address the brady rhythm? It is a very big "Catch 22" and it sounds like the hospital was playing you, if this pt. "Crashed".. How far do we watch a pt. go before we do something? Do you work strictly with MC online or do you have Standing Orders?

[Trauma_Dog]

I think this is reflex bradycardia, possibly due to an increase in icp or hypoxia. With the pt already Dx with a bleed and the fact that the was starting to seize could support the increase in icp theory and the increase in the icp could support the bradycardia as well.

This pts Gloscow coma scale is probily somewhere between a 6-8. I would have intubated this pt to protect his airway as well as attemping to reduce icp. With blood pressures that low and peripheral perfusion diminished your pulse ox readings can be inaccurate.

It is easy for me to holes in your tx plan after the call is over, hell we all make mistakes and usally our supervisors and co-workers point that out to us (I make my share). The differnce is knowledge and correcting thing so they dont happen again. Chapter 10 in your current ACLS manual has an excellent ready on CVA management. Many topics here most medics have not heard of..like anti-hypertensives to cva pts, yet most medics would not even consider doing.

I applaudy our interest in going to medical control to find out why you were denied you request it shows that you care and have devotion, keep up the good work.

------------------
Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX


[This message has been edited by Trauma_Dog (edited May 02, 2000).]

[Paramark14]

I did consider intubation and was prepared to do so if things conntinued to decline but again ICP was weighing heavily on mind. I agree that the brady was related to ICP from the bleed. Some of my peers have indicated that that receiving MC was hesitant to issue orders because the pt. was a direct admit to another unit, I don't know. My med. director said in his opinion TCP would have been his choice in that setting. Thanks for the input guys, this is great!

Mark
EMTP
Indiana

[Medic 16]

Points to ponder!

First of all I agree that this is a catch 22 and if the medical director didn't give you the orders because the pateint was a direct admit - shame on him.

It seems the pateint was having an increase in ICP due to the seizures, bardicardia and hypotension. I think intubation sounds great but,
1.If you would have attempted to intubate the patient you may have cause an increase in ICP yourself.
2. Since the patient had a diagnosed bleed the hypotension may be making things worse because he may not have a high eneough pressure to perfuse his brain, but then again he may.
3. If #2 is corect in he is not perfusing his brain should you increase his heart rate which may increase myocardial O2 demand it may increase his pressure or should you give some fluid.

I don't know about anyone else but the whole head bleed thing seems to be a grey area. First it was fluids, fluids, fluids, now its fluids only in the presence if increasing ICP.