EMERGENCY DEPARTMENT INTRACRANIAL HEMORRHAGE

MANAGEMENT PROTOCOL

This protocol is a guideline for management and can be superseded by clinical judgment

Immediate Emergency Department Physician Protocol

ABCs

Review vitals and finger stick blood sugar

Focused history and physical exam with neurological examination

Time of symptom onset is assumed as the time that the patient was last known to be symptom-free

Stroke Team Notification if Stroke Symptoms <24 hours duration

Neurosurgery Consult

**Stroke Team Notification via AMAC at Ext. 43611 within 5 minutes of patient arrival

Neurology Consult	Stroke Beeper 3886 Neurology Beeper 2545
Radiology Staff	M-F 9am to 4pm Extension 44261 or beeper 5346
	M-F 4pm to 9am Sat & Sun Beeper 1490
CT Scan personnel	Extension 47412
Laboratory personnel	Extension 43895 Supervisor 88145
Neurosurgery Consult	Pager 2009

HPI:

Age

Date/time of ICH onset, (or last time seen normal)

History of head trauma, h/o seizure at onset

PMH/ SH:

Assess for previous CVA (baseline functional status), HTN, dementia, liver disease, cancer

History of tobacco, cocaine, amphetamines, OTC Meds

Is the patient on Coumadin, Heparin, LMWH, or antiplatelet (ASA or Plavix /Aggrenox)?

Does patient have dysfunctional platelets? (Renal failure)

Is the patient intrinsically coagulopathic (Hemophilia, Von Willibrands, etc)

Exam:

Clinical exam and blood pressure

Sources of fever should be treated and antipyretic medications should be administered to lower temperature in febrile patients

Labs

If transferred, review lab data from prior institution

Patient must have 18 or 20 gauge arm IV; a central line alone is inadequate

PT, PTT, INR	Type and Hold
GEM3000	CBC
CK, MB, Troponin I	LFTs
Chem7, Magnesium	D-Dimer, Fibrinogen
Therapeutic Drug Levels	Urine Toxicology screen (age <60 years)

Imaging

EKG

Stat Noncontrast Head CT

Portable Chest X-ray

Head CT findings

Location of blood (deep, superficial, cerebellar, intra-ventricular)

Volume of blood (A*B*C/2) method

Presence of hydrocephalus

Midline shift (measure at septum pellucidum)

Evidence of trauma, contusion, SAH, AVM or underlying mass

Hyperglycemia & Hypoglycemia

Maintain Euglycemia

Seizure Management

Treat any patient with seizure with Ativan 0.1 mg/kg

• Fosphenytoin 20 mg/kg IV

(See status epilepticus protocol if patient continues to seize)

Fosphenytoin 20 mg/kg IV load

• Patients going to OR for neurosurgery

• Consider in non-command following patients or patients with evidence of elevated ICP on Head CT

Hypertension

Maintain SBP between 160-180 and MAP <130 with

• Labetolol 5 to 20 mg bolus and infusion at 2 mg/min (maximum 300 mg/d)

• or Cardene drip 5 to 15 mg/h

• Avoid nitroprusside as this can raise ICP

1. SBP is >200 mm Hg or MAP is >150 mm Hg

Aggressive BP reduction with continuous IV infusion, Check BP Q 5 min

2. If SBP is >180 mm Hg or MAP is >130 mm Hg and evidence or suspicion of elevated ICP

Consider monitoring ICP and reducing BP to keep CPP >60 to 80 mm Hg.

3. If SBP is >180 mm Hg or MAP is >130 mm Hg without evidence or suspicion of elevated ICP

Consider a modest BP reduction (MAP of 110 mm Hg or target blood pressure of 160/90 mm Hg

Check BP Q 15 min

Hypotension

Maintain SBP > 90; begin with isotonic fluid before starting vasopressors

Consider Neosynephrine or Phenylephrine 2–10 mg / kg / min

COAGULOPATHY AND ANTIPLATELET CORRECTION SHOULD

OCCUR WITHOUT DELAY AND BE MANAGED BY A PHYSICIAN

After coagulation reversal, with clinical deterioration or enlargement of ICH on repeated Head CT, additional correction should be given.

Warfarin

Any patient with a history of recent warfarin use, regardless of INR or PT should immediately receive:

1. Vitamin K 10 mg IV over 10 minutes (monitor for hypotension / anaphylaxis) &

2. 50 units/kg of Prothrombin Complex Concentrate (1.Bebulin or 2.Profilnine)

• If PCC unavailable, 15 cc/kg of FFP

CAUTION WITH PCC IF PATIENT WITH RECENT THROMBOTIC EVENT

(e.g. MI, STROKE, PE, DVT) OR PATIENTS IN DIC

Liver failure with known coagulopathy or elevated PT or INR ≥1.2

1. Vitamin K 10 mg IV over 10 minutes (monitor for hypotension / anaphylaxis) &

2. 50 units/kg of Prothrombin Complex Concentrate (Bebulin or Profilnine) &

3. 2 units of FFP

• If PCC unavailable, 15 cc/kg of FFP total

Unfractionated Heparin – Protamine Administration

• 0-30 minutes from heparin administration give 1.0 mg Protamine IV per 100 units heparin

• 31-60 minutes from heparin administration give 0.75 mg Protamine IV per 100 units heparin

• 61-120 minutes give 0.5 mg per 100 units heparin

• >2 hours from heparin administration give 0.3 mg Protamine IV per 100 units heparin

• Protamine: Maximum dose 50 mg, max infusion rate 5 mg/min., monitor for anaphylaxis and hypotension

Low molecular weight Heparin/ Lovenox- Protamine Administration

• 1 mg Protamine IV per 1 mg of enoxaparin given in last 8 hours; If >8 hours since Lovenox, no Protamine

• If bleeding continues: 0.5 mg Protamine IV per 1 mg of enoxaparin in last 8 hours

(BTW john- ACCP 2004 says smaller doses of Protamine can be used if Lovenox given in >8h but does not suggest dose)

Reversal of Platelet Dysfunction: For any patient with antiplatelet (Aspirin, Aggrenox or Clopidogrel) use in last 24 hours and ICH onset within 3 days

1. DDAVP 0.3 mcg/kg x 1 (20 mcg in 50 cc NS over 15-30 minutes) &

2. 6 units of platelets

Renal disease- Patients with increased creatinine

1. DDAVP 0.3 mcg/kg x 1 (20 mcg in 50 cc NS over 15-30 minutes) &

2. 6 units of cryoprecipitate or FFP for clinical deterioration

Thrombocytopenia – transfuse for platelets <50,000

Hemophilia

Factor 8-Adults 40 units / Kg then 20 units / Kg Q12 hours

Peds 50 units / Kg then 25 units / Kg Q12 hours

Factor 9-Adults 80 units / Kg then 40 units / Kg Q24 hours

Peds 100 units / Kg then 50 units / Kg Q24 hours

With Inhibitor

• FEIBA- Factor 8 Inhibitor Bypassing Activity 75 units / Kg Q12 hours

• If ICH worsens give rF7a- Recombinant Factor VIIa 90 units / Kg Q2 hours

Patients with ICH after rTPA (Alteplase)

1. Stop TPA

2. 12 units of cryoprecipitate &

3. 6 units of platelets

Treatment of Intracranial Hypertension (ICHTN)

• Elevate head of bed to 30 degrees; keep head midline

• Analgesia and sedation to minimize agitation

• Mannitol 20% 1 g / Kg bolus (100g if weight unknown)

• Maintenance mannitol 0.5 g/kg q 4-6 h following q 6 hour serum osmolarity / osmolality and replace UOP cc for cc with NS

• Maintenance hypertonic saline: 3% saline at 75 cc/h with goal Na 150-155 meq/L

• Assess for urgent EVD (non-command following exam or symptomatic hydrocephalus)

• If EVD placed give Ancef 1 g IV prior to EVD insertion and one dose 8 hours later

• Set EVD to 10 cmH2O

• If ICP monitoring in place: titrate BP control to keep CPP 60-80 mmHg

• Q15 minute neurological exams to assess for signs of herniation

Miscellaneous

• If Cr elevated >1.0 & IV Contrast, give Mucomyst 600 mg PO BID x 2d and HCO3 drip (3 amps NaHCO3 in 1 liter D5W at 1 cc/kg/h for 1 hour prior to CT and 6 hours after CT

• NS at 75 cc/h unless patient qualifies for hypertonic saline

• Pepcid 20 mg IV BID

• Versed Drip protocol for sedating patients on ventilator or intracranial hypertension

• NPO

Disposition

Monitoring and management of patients with an ICH should take place in an intensive care unit setting

DNR

Recommend careful consideration of aggressive full care during the first 24 hours after ICH onset and postponement of new DNR orders during that time. Patients with previous DNR orders are not included in this recommendation.

Subarachnoid Hemorrhage

• Fosphenytoin 20 mg/kg IV load

• Nimodipine 60 mg PO q 4 h for SBP≥140, 30 mg for SBP 120-140, hold for SBP ≤120

• Keep SBP between ≤160 mmHg with Labetolol drip or Cardene drip (avoid nitroprusside as this can raise ICP) and ≥90 mmHg with Neosynephrine

• Assess for Amicar: if patient prior to SAH day 3 and aneurysm treatment will be delayed >12 hours AND

• NO h/o stroke, MI, PVD or abnormal EKG

• 4g IV over first hour, then 1 g IV q hour, hold 1-3 hours prior to angiogram

• Medications and drips prior to securing aneurysm:

• Continue Amicar or load if patient meets above indications

• Continue phenytoin 300 mg IV QD or Keppra 100 mg IV BID (assure that patient has already received complete 20 mg/kg IV fosphenytoin load)

• Continue Nimodipine 60 mg PO q 4 h for SBP≥140, 30 mg for SBP 120-140, hold for SBP ≤120

• Keep SBP between ≤160 mmHg with Labetolol or Cardene (avoid nitroprusside as this can raise ICP) and ≥90 mmHg with Neosynephrine

• NS at 75 cc/h unless patient qualifies for hypertonic saline (see below)

• Albumin protocol: Give 250 cc of 5% albumin for CVP≤5 q 3 hours

• In grade III-V patients for vasospasm prevention consider Zocor 80 mg PO QD (if LFTs normal) and/or Magnesium drip (20g Mg /1000ml NS): 4 g IV load (200 ml over 2 hours), then 0.5 g/h (25 ml/h) to goal Mg level 2.5-3.5 mg/dL

• Check daily EKG (watch for ↑ PR, QRS, QT interval)

• Monitor q6h Mg level and daily K+, Ca++

• Monitor for toxicity: muscle weakness, decreased alertness, hypotension, respiratory paralysis, loss of deep tendon reflexes