ABSTRACT
Background Recommendations on optimal agents to manage blood pressure (BP) in patients with an intracranial hemorrhage (ICH) are lacking. A case series suggests that hydralazine can cause intracranial pressure (ICP) elevation in an ICH. The purpose of this study was to compare the effects of intravenous (IV) hydralazine to IV labetalol on ICP in patients with ICH. Materials and methods A retrospective chart review from September 2015 to September 2021 on adults admitted to a level I trauma center with ICH, requiring an external ventricular drain or ICP monitor, and pharmacologic intervention with IV hydralazine or IV labetalol. ICP measurements and clinical interventions 0-80 minutes prior to and after medication administration were compared. Data points were excluded if multiple antihypertensive agents were administered. Results A total of 27 patients were included (three received only hydralazine, 13 only labetalol, and 11 both). Twenty-seven doses of hydralazine and 115 doses of labetalol were compared. There was no significant difference in mean ICP 0-80 minutes following hydralazine and labetalol administration (p = 0.283). Of the hydralazine doses, 29.6% received intervention for elevated ICP, while 25.2% of labetalol doses received intervention (p = 0.633). Hydralazine patients received m = 0.56 interventions for ICP, and labetalol patients received m = 0.36 interventions (p = 0.223). Of the patients that required intervention for ICP management, hydralazine patients required m = 1.88 interventions, while labetalol patients required m = 1.41 interventions (p = 0.115). Conclusion There was no significant difference in mean ICP at 0-80 minutes following administration of hydralazine or labetalol. There was also no significant difference in interventions required for elevated ICP management between groups. Larger studies are needed to confirm these findings.
ABSTRACT
BACKGROUND Clostridial myonecrosis, also known as gas gangrene, is a highly lethal necrotizing soft tissue infection. While commonly associated with trauma, clostridial myonecrosis may be the result of parenteral injection of medications. Epinephrine is the most commonly reported medication leading to gas gangrene. CASE REPORT A 60-year-old man presented to the Emergency Department (ED) with "the worst pain in his life" to the right thigh near the site at which he auto-injected epinephrine after multiple bee stings 10-11 h prior to arrival. Initial heart rate was 112 beats/min but all other vital signs were unremarkable at presentation. Due to extreme pain, a computed tomography (CT) scan was ordered, revealing prominent gas within the anterior compartment of the right thigh, mostly involving the vastus lateralis and rectus femoris, suggesting necrotizing fasciitis. Antimicrobials were initiated immediately and the patient was taken for surgical debridement within 70 min after obtaining the CT results. Clostridium perfringens was cultured from the patient's tissue. After several surgical debridement's, appropriate antimicrobial therapy, supportive care, and wound care, the patient's limb remained intact and he was discharged after 11 days. CONCLUSIONS With millions of epinephrine auto-injectors prescribed yearly in the United States, awareness of clostridial gas gangrene following epinephrine auto-injection for the provider may help guide decision-making in patients presenting with extreme pain, redness, or swelling near the injection site after epinephrine injection.