Intracranial Hemorrhage Flashcards
What are the initial basic interventions for a patient with intracranial bleed?
Elevate head of bed Prevent any obstruction of neck veins Mange pain and agitation Normothermia Normoglycemia Don't need seizure prophylaxis
When is neurosurgical intervention more likely to be indicated in intracranial bleed?
Posterior fossa bleed
Mass effect
Midline shift
Hydrocephalus
What are the blood pressure goals in intracranial bleed?
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%
What meds can be used to treat BP in intracranial bleed? (dosing addressed later)
Nicardipine
Labetalol
Clevidipine
How is intubation done in rapidly declining patients with intracranial bleed?
Same as usual RSI
How is intubation done for slowly declining patient with intracranial bleed who you have time to prepare?
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
How is warfarin reversed in intracranial bleed?
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
What is prothrombin complex concentrate (PCC)
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
How are Eliquis and Xarelto reversed?
Eliquis (apixaban), Xarelto (rivaroxaban) Factor Xa inhibitors
Reversed with Kcentra (4F PCC)
How is dabigatran reversed?
Pradaxa (dabigatran), Thrombin inhibitor
Reversed with Praxbind 5g IV bolus
How is antiplatelet therapy reversed in intracranial bleed?
Usually not reversed
Platelets only transfused if low platelets (50,000-100,000) or if going to surgery
What are signs of increased intracranial pressure?
Signs of herniation: pupil derangements (anisocoria), posturing, Cushing triad
POCUS optic sheath >6mm
CT evidence of ICP
What should be done with increased ICP is found?
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
When is labetalol contraindicated in intracranial bleed?
Bradycardia, heart block, bronchospasm, cocaine, decompensated HF
When is nicardipine contraindicated?
Severe aortic stenosis