ED Management of Spontaneous Intracerebral Hemorrhage

• Establish IV access, place patient on monitor, obtain vital signs and place patient on supplemental oxygen.
• Focused neurological exam (check a GCS, cranial nerve exam and then move to the extremities) and general exam of the head, heart, lungs and abdomen.
• History is very important, aimed at establishing time of onset, progression of symptoms, medication (specifically anticoagulation), recent trauma or surgery, illicit drug use, cancer and liver disease (which can cause coagulopathies).
• Obtain labs (CBC, BMP, Troponin, INR, PTT) and rapid neuro imaging, starting with CT head non-contrast. It is not unreasonable to consider a CTA head, but a non-contrast CT should always be obtained first.
• If intubation is being considered for airway protection, consider etomidate 0.3mg/kg to maintain cerebral perfusion pressure, and any choice of paralytic agent. Post-intubation sedation should be effective but allow for neurologic examination.
• Hyperventilating patients to reduce PaCO2 has been shown to have poor neurologic outcomes and is not recommended.
• Blood pressure goals should be aimed at reducing SBP to <140mmHg
• Elevate the head of the bed to 30 degrees
• Consults to neurosurgery, critical care and/or neurocritical care are very important! If you do not have these services at your hospital than rapid transport is essential.
• Other Considerations
• Identify if patient is on anticoagulation and reverse them quickly!
• Hypertonic saline has been shown to be more effective than mannitol in decreasing ICP, but you should discuss preference with neurosurgery.

References

• Goldstein JN, Gilson AJ. Critical care management of acute intracerebral hemorrhage. Curr Treat Options Neurol. 2011;13(2):204-16.
• Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-60.
• Roberts BW, Karagiannis P, Coletta M, Kilgannon JH, Chansky ME, Trzeciak S. Effects of PaCO2 derangements on clinical outcomes after cerebral injury: A systematic review. Resuscitation. 2015;91:32-41.