ALNW:Intracerebral Hemorrhage

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Principles of Management

Controlling severe hypertension, which will extend the bleed, and providing adequate cerebral blood flow, to minimize the effects of local ischemia, requires a fine balance. Oxygenation, ventilation and circulation must be managed meticulously. While the ideal blood pressure to target is a subject to debate, expert medical opinion supports more aggressive blood pressure management. Stabilization and Transport:

Airway/Breathing

• Administer O2 to maintain saturations > 94%
• Intubate for airway control and/or deteriorating neuro status
• Use normal respiratory rates and tidal volumes
• Maintain PaCO2 ~35-45 via ABG/I-stat (flights > 30 mins)

Cardiovascular

• Requires good working IV. If tenuous or patient unstable, 2 IVs recommended with LR or NS
• Administer LR or NS, avoid dextrose containing fluids
• Continuous cardiac monitoring.

BP goals

(after adequate sedation and analgesia)

• • Prehospital: SBP <220 and DBP <120
    • antihypertensives after 1x SBP >220 or DBP> 120
  • Interfacility: (confirmed by CT)
    • ICH: SBP 140-160
      • antihypertensives after 2x SBP >160
    • SAH: SBP 100-120
      • antihypertensives after 2x SBP >120

Management of hypertension

• Labetalol: short-acting beta blocker, quick onset, anti-hypertensive agent
  • Indication:
    • Flight < 30 minutes
    • Initial therapy while preparing nicardipine drip
    • HR > 60
  • Contraindications: HR < 60
• Nicardipine: short-acting, titrateable, calcium channel blocker (vasodilator)
  • Indication:
    • Flight longer than 30 minutes
    • HR <60.
    • SBP <100: turn drip off and give IV bolus of 250-500ml crystalloid
• Nitrates or nitroprusside initiated by referring facility for hypertension should be discontinued for transport. hypertension will be managed following guidelines above.

Management of hypotension

• Discuss threshold for utilization of vasopressors (and type) with medical control even if the patient is normotensive. If on anti-hypertensive infusion, consider titrating or stopping medication.
  • Prehospital: If two consecutive systolic BP < 100, fluid bolus 250-500ml increments, if no immediate contact available with medical control. In discussion with medical control, consider phenylephrine or norepinephrine for BP unresponsive to fluids.
  • Interfacility: For systolic BP < 100, consider fluids as above and discuss addition of vasopressors as above with medical control. Maintain normothermia.

Coagulopathy

• Consider FFP and Vitamin K (IFT) if patient is excessively anti-coagulated( INR > 1.5, patient on ASA or clopidigrel. Consult with Medical Control.
• Consider platelets if platelet count < 100K. Consult with Medical Control.

Neurological:

• Provide analgesia and sedation as needed
  • Analgesia: morphine or fentanyl IV incrementally for pain/ discomfort
  • Sedation: lorazepam or midazolam IV incrementally for anxiety or sedation
• Maintain C-spine precautions if any suspicion of neck trauma
• Transport with HOB at 30°
• Avoid flexion/rotation of neck. Maintain neck and head midline
• Avoid restrictive ETT taping
• Recheck pupils and GCS frequently
• Take care with interventions that may increase agitation leading to increased ICP (e.g. OG/NG unless clinically indicated)
• Increased ICP management per Increased ICP Policy
  • Treat observed pupillary changes of 2 mm or more
  • Treat observed GCS decreases of 2 points or more
• Monitor for and treat seizure activity (see seizure policy)

GI

• Insert orogastric tube if indicated

GU

• Consider foley catheter for interfacility transfers

Authors

Andrew Mason, Ross Donaldson, Neil Young, Michael Holtz