INTRACRANIAL HEMORRHAGE

Question 1

MANAGEMENT

Answer 1

ABCs

Early neurosurgical consultation

Reversal of anticoagulation
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

Blood Pressure Control Controversial
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

Blood Glucose Control
< 10

Temperature Management

Control ICP
Elevate head of bed to 30 degrees
Mannitol 0.5-1 g/kg intravenous
3% hypertonic saline 100 mL intravenous
Intubate, sedate, +/- paralyze
Drain excessive CSF with intraventriculoperitoneal shunt

Seizure prophylaxis

INVESTIGATIONS

CBC, Lytes, Cr
INR, PTT, Fibrinogen
Anti-Xa for RiveroXaban / ApiXaban
Toxicology
ABG/VBG if intubated
CT Angiography

Question 2

DOCUMENTATION

Answer 2

HPI
Time of symptom onset
Medications (HTN, Anticoagulants)

CT HEAD

Question 3

DDX

Answer 3

Extra-Axial:
Subarachnoid
Subdural
Epidural

Intra-Axial:
Intracerebral