INTRACEREBRAL (INTRA-PARENCHYMAL) HEMORRHAGE

Question 1

DOCUMENTATION

Answer 1

CLINICAL FEATURES
Headache (severe, acute)
Weakness
AMS
Vomiting

HTN (especially DBP > 110)
GCS
Pupils
Lateralizing Signs

Monitor Cushing’s Triad: HTN, Bradycardia, Abnormal Respiratory Pattern

Question 2

MANAGEMENT

Answer 2

INVESTIGATIONS
CT Head Non Contrast
+/- Followed by
CTA

MANAGEMENT STEPS:
1. Airway protection PRN
2. BP Control
3. Anticoagulation Reversal
4. Analgesia and Antipyretics
5. Management of Intracranial HTN
6. Neurosurgical Consultation
7. Blood Glucose Control

1. AIRWAY PROTECTION PRN

avoid sudden spikes or drops in mean arterial pressure (MAP) or SBP
Consider etomidate 0.3 mg/kg/dose

2. BP CONTROL

Avoid sudden spikes or drops in MAP or SBP.
Intial blood pressure 150-220 -> Target reduction of BP to 130-150 mm Hg

If SBP > 220 -> Target reduction SBP by no greater than 25%

BP management should ideally be initiated within 2 hours of ICH and goal SBP reached within 1 hour of initiating.

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

Labetolol:
10-20 mg IV bolus over 2 minutes, then 20-80 mg IV bolus every 10-15 minutes (maximum total dose 300 mg)

Labetalol intravenous bolus can be followed by a continuous infusion of 0.5-2 mg/minute (maximum total dose 300 mg).

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

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

3. ANTICOAGULATION 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 in 2 doses of 2.5 g
OR (if idarucizumab is not available)
Octaplex (PCC) 80mL (2000 U)
fXa: andexamet, TXA
Thrombocytopenia: platelet transfusion

4. ANALGESIA AND ANTIPYRETICS
5. MANAGEMENT OF INTRACRANIAL HTN

Monitor Cushing’s Triad: HTN, Bradycardia, Abnormal Respiratory Pattern

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

6. NEUROSURGICAL CONSULTATION
   Document Time of Call, time answered
7. BLOOD GLUCOSE CONTROL
   Target < 10
8. REPEAT CT HEAD
   Repeat imaging at 6 hrs if clinically stable

Question 3

KEY CONCEPTS

Answer 3

DEFINITION
Bleeding WITHIN the brain tissue from parenchyman vessels, with potential to extend into the ventricular system

ETIOLOGY
Rupture of small vessels due to:
Chronic HTN
Vascular Malformation
Amyloid Angiopathy
Venous Thrombosis / Infarction
Tumour