Intracranial Hemorrhage

Question 1

What are the initial basic interventions for a patient with intracranial bleed?

Answer 1

Elevate head of bed
Prevent any obstruction of neck veins
Mange pain and agitation
Normothermia
Normoglycemia
Don't need seizure prophylaxis

Question 2

When is neurosurgical intervention more likely to be indicated in intracranial bleed?

Answer 2

Posterior fossa bleed
Mass effect
Midline shift
Hydrocephalus

Question 3

What are the blood pressure goals in intracranial bleed?

Answer 3

Avoid hypotension (MAP< 75-80)
For BP 150-220 goal is 140
For BP >220 goal is 160
If chronic >200 goal is 180 or decrease by 25%

Question 4

What meds can be used to treat BP in intracranial bleed? (dosing addressed later)

Answer 4

Nicardipine
Labetalol
Clevidipine

Question 5

How is intubation done in rapidly declining patients with intracranial bleed?

Answer 5

Same as usual RSI

Question 6

How is intubation done for slowly declining patient with intracranial bleed who you have time to prepare?

Answer 6

Neuroprotective Intubation:
Elevate HOB to 20 degrees
Titrate BP 140-160 before intubation
Have BP meds at bedside: nicardipine/push dose epi
Avoid hypoxemia: preoxygenate and apneic oxygenation
Consider pretreatment with fentanyl 3mcg/kg given over 30-60 seconds 3 minutes before intubation to curb sympathetic response
Usual meds unless hypotensive can use ketamine
Post-intubation sedation as usual

Question 7

How is warfarin reversed in intracranial bleed?

Answer 7

Treat empirically even before INR comes back
Vitamin K 10mg IV over 10 minutes
2500 units Kcentra
Check INR 30 minutes after infusion, give additional Kcentra if INR>1.5

Question 8

What is prothrombin complex concentrate (PCC)

Answer 8

PCC is generally factor IX used for hemophilia B, but also contains factors II and X, and if 4-factor, than also has VII.
Used to reverse warfarin or other Vit. K factor deficiencies

Question 9

How are Eliquis and Xarelto reversed?

Answer 9

Eliquis (apixaban), Xarelto (rivaroxaban) Factor Xa inhibitors
Reversed with Kcentra (4F PCC)

Question 10

How is dabigatran reversed?

Answer 10

Pradaxa (dabigatran), Thrombin inhibitor

Reversed with Praxbind 5g IV bolus

Question 11

How is antiplatelet therapy reversed in intracranial bleed?

Answer 11

Usually not reversed

Platelets only transfused if low platelets (50,000-100,000) or if going to surgery

Question 12

What are signs of increased intracranial pressure?

Answer 12

Signs of herniation: pupil derangements (anisocoria), posturing, Cushing triad
POCUS optic sheath >6mm
CT evidence of ICP

Question 13

What should be done with increased ICP is found?

Answer 13

Elevate head of bed
Head in neutral position
Treat agitation and pain
Osmotic therapy: Hypertonic saline 3% x 250mL over 10 minutes
Mannitol 0.5-1 g/kg (watch for fluid shift, place foley and match urine losses with IV fluids)
If herniation, hyperventilate to pCO2 30-35
Avoid steroids

Question 14

When is labetalol contraindicated in intracranial bleed?

Answer 14

Bradycardia, heart block, bronchospasm, cocaine, decompensated HF

Question 15

When is nicardipine contraindicated?

Answer 15

Severe aortic stenosis

Question 16

How well is prognosis determines in early intracranial bleed?

Answer 16

Prognosis is often inaccurate in first 24-48 hours and all interventions should be done early on.

Question 17

How is nicardipine dosed in intracranial bleed?

Answer 17

5mg/hr initial rate, titrate by 2.5mg/hr every 5-15min with max of 15mg/hr

Question 18

How is Labetalol dosed in intracranial bleed?

Answer 18

10mg IV bolus followed by 2mg/min titrated by 0.5mg/min every 15 min for max of 8mg/min

Question 19

What is the dosing of Kcentra for eliquis and xarelto?

Answer 19

50 units/kg with max of 5,000 units

Question 20

How is pradaxa reversed if praxbind is unavailable?

Answer 20

Give Kcentra