INTRACEREBRAL (INTRA-PARENCHYMAL) HEMORRHAGE

Question 1

DOCUMENTATION

Answer 1

CLINICAL FEATURES

Sudden Onset Headache

Stroke Symptoms

Question 2

MANAGEMENT

Answer 2

1. CT HEAD NON CONTRAST

Consider CTA to assess for hemorrhage expansion risk

2. EARLY NEUROSURGICAL CONSULT
3. BLOOD PRESSURE CONTROL
   Intial blood pressure 160-220 -> Target reduction of BP to 140-160 mm Hg

If SBP > 220 -> Target reduction to SBP 140-180

Assess q 15 min until desired BP target is achieved and maintained for the first 24 hrs

Labetolol:
Dosing: 5-20 mg IV with additional doses 20, 40, 80 to total 300 q 10-15 min
OR
1-2 mg / min

C/I:
Pheochromocytoma, CHF, Asthma, Heart Block

Hydralazine:
Dosing: 5 mg IV, repeat 5-10 mg q 20 min
Goal DBP<110

4. ANTICOAGULANT REVERSAL
   Warfarin with elevated INR: Octaplex (PCC) 80mL (2000 U) + 10 mg Vit K IV, hold Warfarin, repeat INR

Rivaroxaban / Apixaban / Edoxaban: Octaplex (PCC) 80mL (2000 U) +/- 10 mg Vit K IV if elevated INR

Heparin: Protamine Sulfate (time dependent dosing)

Dabigatran: idarucizumab 5 g IV
fXa: andexamet, TXA
Thrombocytopenia: platelet transfusion

5. BLOOD GLUCOSE TARGET
   < 10
6. ICP MANAGEMENT
   Elevate head of bed to 30 degrees
   Mannitol 0.5-1 g/kg intravenous
   20 g / 100 ml
   3% hypertonic saline 100 mL intravenous
   Intubate, sedate, +/- paralyze
   Drain excessive CSF with intraventriculoperitoneal shunt
7. SEIZURE PROPHYLAXIS
   Keppra