Can Stemitil (prochlorperazine) be given in cases of Intracranial Hemorrhage (ICH)?

Can Stemitil (Prochlorperazine) Be Given in Intracranial Hemorrhage?

Stemitil (prochlorperazine) can be used cautiously in ICH patients for nausea and vomiting, but requires careful consideration of its potential to lower blood pressure and cause sedation, which could complicate neurological monitoring and blood pressure management.

Key Considerations for Antiemetic Use in ICH

Blood Pressure Effects

• Prochlorperazine has hypotensive properties that could interfere with the critical blood pressure targets in acute ICH management 1, 2
• The American Heart Association/American Stroke Association recommends maintaining systolic blood pressure between 130-150 mm Hg in acute ICH, with avoidance of drops below 130 mm Hg (Class III: Harm) 1
• Any medication that causes hypotension could compromise cerebral perfusion pressure, which must be maintained ≥60 mm Hg at all times 1, 3

Neurological Monitoring Concerns

• Prochlorperazine causes sedation and altered mental status, which can mask neurological deterioration—a critical concern in ICH where frequent neurological assessments are essential 4
• Guidelines emphasize the importance of detailed neurological assessment using standardized scales (NIHSS, GCS) and surveillance for complications 4
• Reassessment of neurological status every 15 minutes is recommended during active blood pressure reduction 1

Seizure Risk Considerations

• Prochlorperazine lowers the seizure threshold, which is problematic given that clinical seizures occur in up to 16% of ICH patients, particularly with lobar hemorrhages 4
• Prophylactic antiseizure drugs are not routinely recommended and may be associated with increased death and disability 4
• Adding a medication that increases seizure risk without clear benefit should be avoided 4

Practical Approach to Nausea Management in ICH

Preferred Strategy

• Prioritize non-pharmacological measures first: head elevation (which also helps with ICP management), small frequent meals when appropriate 4
• If antiemetics are necessary, consider alternatives with less impact on blood pressure and consciousness:
  • Ondansetron (5-HT3 antagonist) has minimal hemodynamic effects
  • Metoclopramide in low doses, though it also has dopaminergic effects

When Prochlorperazine Might Be Acceptable

• After the acute phase (beyond 24-48 hours) when hematoma expansion risk is lower and blood pressure has stabilized 4, 5
• In patients with small, stable hemorrhages without mass effect or elevated ICP 4
• When continuous blood pressure monitoring via arterial line is in place 1
• Only if nausea is severe and refractory to safer alternatives 6

Absolute Cautions

• Avoid in the first 24 hours when hematoma expansion risk is highest and aggressive monitoring is critical 4, 5
• Do not use in patients with depressed mental status disproportionate to brain injury (concern for subclinical seizures) 4
• Contraindicated if systolic blood pressure is already <140 mm Hg or trending downward 1, 2
• Avoid in patients requiring intensive ICP management or with clinical signs of elevated ICP 3

Common Pitfalls to Avoid

• Do not assume that routine antiemetic use is benign in ICH—every medication must be weighed against the critical need for neurological monitoring and blood pressure control 4, 1
• Do not use prochlorperazine prophylactically; only treat symptomatic nausea when benefits clearly outweigh risks 6
• Remember that sedation from antiemetics can be misinterpreted as neurological deterioration, potentially triggering unnecessary interventions or delaying recognition of true complications 4

The fundamental principle is that in acute ICH, morbidity and mortality are driven by hematoma expansion, elevated ICP, and secondary brain injury—any medication that interferes with monitoring these processes or managing blood pressure should be used only when absolutely necessary and with heightened vigilance 4, 1, 6, 5.