- Based on the location of blood
- Control of elevated blood pressureThe exact number to which the blood pressure should be reduced remains unclear. But a reduction SBP of 140mmHg appress safe. There has been a concern that acutely lowering blood pressure could lead to ischemic brain injury in the peri-hematoma region, but this risk has not been supported by recent studies.American Heart Association/American Stroke Association Guidelines for the Management of Intracerebral Hemorrhage suggest reducing the blood pressure to <160/90 mmHg or a mean arterial pressure (MAP) <110 mmHg. In patients with potential for elevated ICP, a cerebral perfusion pressure (CPP) of >60 mmHg should be maintained.
Go for quick acting and titratable agents like IV calcium channel blocker infusions (nicardipine or clevidipine) or Labetalol. The worst thing that you can do for these patients is to start them on a nitroprusside or nitroglycerine drip. These dugs cause cerebral vasodilation and can further increase the ICP.
- Correction of coagulopathyFor some reason, we tend to forget this. But reversing blood thinners and anticoagulants is one of the most crucial steps while managing these patients. A quick guide on reversing these medication is mentioned in the table below:
- Need for early surgical intervention and hematoma evacuation
- Patients with cerebellar hemorrhage who are deteriorating neurologically
- Brainstem compression
- Lobar ICH with hematoma volume >30 cc and within 1 cm of the cortical surface
- Significant life-threatening mass effect
- DNR is a self fulfilling prophecy. Give them the best chance.
- Do the ABCs, reverse blood thinners/anticoags and control BP (140 SBP is acceptable)
- Get neurosurgery involved ASAP
- When you handover, make sure to convey the volume, location, medication reversal.
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- Frontera, Jennifer A., et al. "Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage." Neurocritical care (2015): 1-41.