Intracranial Hemorrhage Management Protocol

Imaging

CT Head

• Location of blood (deep, superficial, cerebellar, intra-ventricular)
• Volume of blood (ABC/2) method (performed by neurology)
• Presence of intraventricular blood or hydrocephalus
• Midline shift (measure at septum pellucidum)
• Evidence of trauma, contusion, SAH, AVM or underlying mass
• EKG, Portable Chest X-ray

CTA Head/Neck

• Look for spot sign (sign in acute intracerebral hemorrhage representing the focal accumulation/pooling/extravasation of contrast containing blood within the hematoma)

Managing Complications

• Seizure: Treat any patient with seizure with Ativan 0.1 mg/kg (max: 8 mg) & Fosphenytoin (or phenytoin equivalent) 20 mg/kg IV load or Levetiracetam (Keppra) 1 g /IV. No prophylactic AEDs as does not improve outcome and is associated with worse cognitive outcome.

• Hypertension: Maintain SBP between 160-180 and MAP <130

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

  • OR Cardene drip 5 to 15 mg/h OR Clevidipine Infusion (start 1-2mg/hr, double every 90sec, max dose 32mg/hr)

  • Avoid nitroprusside as this can raise ICP

  • If SBP is >200 mm Hg or MAP is >150 mm Hg: Aggressive BP reduction with continuous IV infusion, Check BP Q 5 min

  • 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.

  • 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 if needed

Treatment of Intracranial Hypertension (ICHTN)

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

• Analgesia and sedation to minimize agitation; if continues, intubate and sedate

• Mannitol 20% 1g /Kg bolus (or 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

• Hyperventilation with Ambu-Bag (should do for a few minutes to reverse ICH or signs of herniation)

• 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

Coagulopathy & Antiplatelet Correction

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

• Vitamin K 10 mg IV (10 mg in 10 ml IV push) over 10 minutes (monitor for hypotension /anaphylaxis) &

• 50 IU/kg of Prothrombin Complex Concentrate (1.Bebulin or 2.Profilnine); If PCC unavailable, 15-20 ml /kg of FFP CAUTION WITH PCC IF PATIENT WITH RECENT THROMBOTIC EVENT (e.g. MI, STROKE, PE, DVT) OR PATIENTS IN DIC

Unfractionated Heparin - Protamine Administration

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

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

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

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

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

Low molecular weight Heparin/Lovenox - Protamine Administration

• Enoxaparin (Lovenox): 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

• Protamine has negligible reversal effects on danaparoid and fondaparinux

• Dalteparin or tinzaparin: 1 mg protamine for each 100 anti-Xa IU of dalteparin or tinzaparin;

  • If bleeding, consider additional dose of 0.5 mg for each 100 anti-Xa IU of dalteparin/tinzaparin

Direct thrombin inhibitors Argatroban, Hirudin (Bivalirudin, Lepirudin), Dabigatran (Pradaxa)

• There is no established reversal agent for these drugs.

• For reversal consider antifibrinolytic such as amicar

Liver failure with known coagulopathy or elevated PT or INR ≥1.5

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

• 50 IU/kg of Prothrombin Complex Concentrate (Bebulin or Profilnine) OR If PCC unavailable, 15-20 ml/kg of FFP total &

• If INR ≥ 2.0, give 15-20 ml/kg of FFP

Note: INR does not correctly depict the coagulation state of liver failure patients and it was developed for monitoring Coumadin therapy, thereby INR can be normal but the patient could be bleeding clinically.

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

• DDAVP 0.3 mcg/kg x 1 (20 mcg in 50 cc NS over 15-30 minutes) & One apheresis platelet unit

• For patients with von Willebrand disease: DDAVP 0.3 mcg/kg x 1 (20 mcg in 50 cc NS over 15-30 minutes)

Renal disease

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

• 10 units of cryoprecipitate or FFP (?) for clinical deterioration

• Transfuse packed RBC if Hct≤27%

4) Thrombocytopenia: Transfuse for platelets <50,000

Hemophilia (without inhibitor)

• Factor 8 - Adults 40 U/kg -> 20 U/kg Q12; Peds 50 U/kg -> 25 U/kg Q12

• Factor 9 - Adults 80 U/kg -> 40 U/kg Q24; Peds 100 U/kg -> 50 U/kg Q24

• With inhibitor

  • FEIBA- Factor 8 Inhibitor Bypassing Activity 75 U/kg Q12 hours

  • If ICH worsens give rF7a- Recombinant Factor VIIa 90 U/kg Q2 hours

Patients with ICH after rTPA (Alteplase or Reteplase)

• Stop TPA

• Check CBC, PT, PTT, platelets, fibrinogen, DDimer

• 10 units of cryoprecipitate (0.15 units/kg) + 1U apharesis platelets

• If still bleeding at 1 hour and fibrinogen still <100 mg/dL repeat cryoprecipitate dose (0.15units/kg).

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

• Maintain NPO

• Code status: 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

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

Subarachnoid Hemorrhage Management

• 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

• 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; GIVE 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 1000 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

ICU monitoring

• 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