Hemorrhagic Stroke in Emergency Medicine Medication
- Author: David S Liebeskind, MD; Chief Editor: Rick Kulkarni, MD more...
Medication Summary
The goals of pharmacotherapy for hemorrhagic stroke are to reduce morbidity and to prevent complications. Medications used in the treatment of acute stroke include anticonvulsants such as diazepam to prevent seizure recurrence, antihypertensive agents such as labetalol to reduce BP and other risk factors of heart disease, and osmotic diuretics such as mannitol to decrease intracranial pressure in the subarachnoid space.
Anticonvulsants
Class Summary
Anticonvulsants prevent seizure recurrence and terminate clinical and electrical seizure activity. These agents are used routinely to avoid seizures that may be induced by cortical damage.
Fosphenytoin (Cerebyx)
Fosphenytoin is a diphosphate ester salt of phenytoin that acts as water-soluble prodrug of phenytoin. Phenytoin, in turn, stabilizes neuronal membranes and decreases seizure activity.
To avoid the need to perform molecular-weight-based adjustments when converting between fosphenytoin and phenytoin sodium doses, express the dose as phenytoin sodium equivalents. Although fosphenytoin can be administered IV and intramuscularly (IM), the IV route is the route of choice and should be used in emergency situations.
Concomitant administration of an IV benzodiazepine will usually be necessary to control status epilepticus. The antiepileptic effect of phenytoin, whether given as fosphenytoin or parenteral phenytoin, is not immediate.
Phenytoin (Dilantin)
Phenytoin may act in the motor cortex, where it may inhibit spread of seizure activity, as well as in the brainstem centers responsible for the tonic phase of grand mal seizures.
All doses should be individualized. In addition, a larger dose before retiring should be administered if the dose cannot be divided equally.
Benzodiazepines
Class Summary
Benzodiazepines are commonly used to control seizure activity and recurrence. Agents such as lorazepam and diazepam are often used in combination with either phenytoin or fosphenytoin loading.
Diazepam (Diastat, Diazemuls, Valium)
Diazepam is used to control active seizures by modulating the postsynaptic effects of gamma-aminobutyric acid type A (GABA-A) transmission, resulting in an increase in presynaptic inhibition. It appears to act on part of the limbic system, the thalamus, and hypothalamus, to induce a calming effect, as well as acts as an effective adjunct for the relief of skeletal muscle spasm caused by upper motor neuron disorders.
Diazepam should be augmented by longer-acting anticonvulsants, such as phenytoin or phenobarbital, because it rapidly distributes to other body fat stores.
Lorazepam (Ativan)
Lorazepam is a short-acting acting benzodiazepine with a moderately long half-life that has become the drug of choice in many centers for treating active seizures.
Beta-adrenergic blockers
Class Summary
Beta-blockers are used to reduce blood pressure and risk factors for heart disease. Selective beta-blockers block beta-1 receptors more than beta-2 receptors; nonselective beta-blockers block both beta-1 and beta-2 receptors.
Labetalol (Trandate)
Labetalol blocks beta1-, alpha-, and beta2-adrenergic receptor sites to decrease BP. It is administered as a 5-20 mg IV bolus over 2 minutes, then as a continuous infusion at 2 mg/min, not to exceed 300 mg/dose.
Esmolol (Brevibloc)
Esmolol is an ultra-short-acting agent that selectively blocks beta1-receptors with little or no effect on beta2-receptor types. This drug is particularly useful in patients with elevated arterial pressure, especially if surgery is planned, and its short half-life of 8 minutes allows for titration and quick discontinuation, if necessary.
Esmolol is also useful in patients at risk for experiencing complications from beta-blockade, particularly those with reactive airway disease, mild to moderate left-ventricular dysfunction, and/or peripheral vascular disease.
Vasodilators
Class Summary
Vasodilators lower blood pressure through direct vasodilation and relaxation of the vascular smooth muscle.
Hydralazine (Apresoline)
Hydralazine decreases systemic resistance through direct vasodilation of arterioles and is used to treat hypertensive emergencies. The use of a vasodilator will reduce the stroke volume ratio (SVR), which, in turn, may allow forward flow, improving cardiac output.
Calcium channel blockers
Class Summary
Calcium channel blockers are used to lower blood pressure by relaxing the blood vessels and increasing the amount of blood and oxygen that is delivered to the heart while reducing the heart’s workload.
Nicardipine (Cardene, Cardene IV, Cardene SR)
Nicardipine relaxes coronary smooth muscle and produces coronary vasodilation, which, in turn, improves myocardial oxygen delivery and reduces myocardial oxygen consumption.
Angiotensin converting enzyme inhibitors
Class Summary
ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion. Some examples of ACE inhibitors include enalapril (Vasotec), ramipril (Altace) and lisinopril (Zestril).
Enalapril (Vasotec)
Enalapril prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased levels of plasma renin and a reduction in aldosterone secretion. It helps control blood pressure and proteinuria.
Ramipril (Altace)
Ramipril prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased levels of plasma renin and a reduction in aldosterone secretion.
Lisinopril (Zestril)
Lisinopril prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.
Angiotensin receptor blockers
Class Summary
Angiotensin-receptor blockers may be used as an alternative to ACE inhibitors in patients who develop adverse effects, such as a persistent cough. Examples of angiotensin receptor blockers are losartan (Cozaar), valsartan (Diovan), and candesartan (Atacand).
Losartan (Cozaar)
Losartan blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. It may induce a more complete inhibition of the renin-angiotensin system than ACE inhibitors, does not affect the response to bradykinin, and is less likely to be associated with cough and angioedema.
Candesartan (Atacand)
Candesartan blocks vasoconstriction and the aldosterone-secreting effects of angiotensin II. It may induce a more complete inhibition of the renin-angiotensin system than ACE inhibitors, does not affect response to bradykinin, and is less likely to be associated with cough and angioedema.
Valsartan
Valsartan produces direct antagonism of angiotensin II receptors. It displaces angiotensin II from the AT1 receptor and may lower blood pressure by antagonizing AT1-induced vasoconstriction, aldosterone release, catecholamine release, arginine vasopressin release, water intake, and hypertrophic responses.
Thiazide Diuretics
Class Summary
Thiazide diuretics inhibit sodium and chloride reabsorption in the distal tubules of the kidney, resulting in increased urinary excretion of sodium and water. Examples of thiazide diuretics are hydrochlorothiazide and chlorthalidone.
Hydrochlorothiazide (Microzide)
Hydrochlorothiazide inhibits the reabsorption of sodium in distal tubules, causing increased excretion of sodium and water, as well as potassium and hydrogen ions.
Chlorthalidone (Thalitone)
Chlorthalidone inhibits the reabsorption of sodium in distal tubules, causing increased excretion of sodium and water, as well as potassium and hydrogen ions.
Osmotic Diuretics
Class Summary
Osmotic diuretics, such as mannitol, may be used to decrease intracranial pressure in the subarachnoid space. As water diffuses from the subarachnoid space into the intravascular compartment, pressure in the subarachnoid compartment may decrease.
Mannitol (Osmitrol)
Mannitol reduces cerebral edema with help of osmotic forces as well as decreases blood viscosity, resulting in reflex vasoconstriction and lowering of intracranial pressure.
Antipyretics, Analgesics
Class Summary
As hyperthermia may exacerbate neurologic injury, these agents may be given to reduce fever and relieve pain.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
Acetaminophen reduces fever, maintains normothermia, and reduces headache.
Vitamin, Fat Soluble
Class Summary
Vitamin K is used to promote the formation of clotting factors. Phytonadione can overcome the competitive block produced by warfarin and other related anticoagulants.
Phytonadione (Mephyton)
Phytonadione can overcome the competitive block produced by warfarin and other related anticoagulants. Vitamin K-3 (menadione) is not effective for this purpose. There is a delay of the clinical effect for several hours while liver synthesis of the clotting factors is initiated and plasma levels of clotting factors II, VII, IX, and X are gradually restored.
Phytonadione should not be administered prophylactically and is used only if evidence of anticoagulation exists. The required dose varies with the clinical situation, including the amount of anticoagulant ingested and whether it is a short-acting or long-acting anticoagulant.
Blood products
Class Summary
These agents are indicated for the correction of abnormal hemostatic parameters.
Fresh Frozen Plasma
Fresh frozen plasma is the fluid component of blood containing the soluble clotting factors that has been separated from a unit of blood and frozen to be used in patients with blood-product deficiencies.
Platelets
Platelets are fragments of large bone marrow cells found in the blood that play a role in blood coagulation. A single random donor unit of platelets per 10 kg is administered in adults when the platelet count drops below 50,000/µL.
Prothrombin complex concentrate (Bebulin VH, Profilnine SD)
Prothrombin complex concentrate (PCC) is a mixture of vitamin K-dependent clotting factors found in normal plasma that replaces deficient clotting factors, provides an increase in plasma levels of factor IX, and can temporarily correct a coagulation defect in patients with factor IX deficiency.
Heparin antidote
Class Summary
This agent is used to neutralize the effects of anticoagulants.
Protamine
Protamine sulfate forms a salt with heparin and neutralizes its effects. The dosage administered is dependent on the time since heparin was given.
Hemostatic Agents
Class Summary
These agents improve bleeding time and hemostasis.
Desmopressin acetate (DDAVP, Stimate)
Releases von Willebrand protein from endothelial cells. Improves bleeding time and hemostasis in patients with some vWf (mild and moderate von Willebrand disease without abnormal molecular forms of von Willebrand protein). Effective in uremic bleeding. Tachyphylaxis usually develops after 48 h, but the drug can be effective again after several days.
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