Intracranial Hemorrhage Flashcards

1
Q

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

A
Elevate head of bed
Prevent any obstruction of neck veins
Mange pain and agitation
Normothermia
Normoglycemia
Don't need seizure prophylaxis
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2
Q

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

A

Posterior fossa bleed
Mass effect
Midline shift
Hydrocephalus

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3
Q

What are the blood pressure goals in intracranial bleed?

A

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%

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4
Q

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

A

Nicardipine
Labetalol
Clevidipine

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5
Q

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

A

Same as usual RSI

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6
Q

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

A

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

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7
Q

How is warfarin reversed in intracranial bleed?

A

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

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8
Q

What is prothrombin complex concentrate (PCC)

A

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

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9
Q

How are Eliquis and Xarelto reversed?

A

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

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10
Q

How is dabigatran reversed?

A

Pradaxa (dabigatran), Thrombin inhibitor

Reversed with Praxbind 5g IV bolus

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11
Q

How is antiplatelet therapy reversed in intracranial bleed?

A

Usually not reversed

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

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12
Q

What are signs of increased intracranial pressure?

A

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

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13
Q

What should be done with increased ICP is found?

A

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

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14
Q

When is labetalol contraindicated in intracranial bleed?

A

Bradycardia, heart block, bronchospasm, cocaine, decompensated HF

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15
Q

When is nicardipine contraindicated?

A

Severe aortic stenosis

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16
Q

How well is prognosis determines in early intracranial bleed?

A

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

17
Q

How is nicardipine dosed in intracranial bleed?

A

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

18
Q

How is Labetalol dosed in intracranial bleed?

A

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

19
Q

What is the dosing of Kcentra for eliquis and xarelto?

A

50 units/kg with max of 5,000 units

20
Q

How is pradaxa reversed if praxbind is unavailable?

A

Give Kcentra