ALNW:Intracerebral Hemorrhage

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Principles of Management

Controlling severe hypertension, which will extend the bleed, and providing adequate cerebral blood flow, to minimize the effects of local ischemia, requires a fine balance. Oxygenation, ventilation and circulation must be managed meticulously. While the ideal blood pressure to target is a subject to debate, expert medical opinion supports more aggressive blood pressure management. Stabilization and Transport:

Airway/Breathing

  • Administer O2 to maintain saturations > 94%
  • Intubate for airway control and/or deteriorating neuro status
  • Use normal respiratory rates and tidal volumes
  • Maintain PaCO2 ~35-45 via ABG/I-stat (flights > 30 mins)

Cardiovascular

  • Requires good working IV. If tenuous or patient unstable, 2 IVs recommended with LR or NS
  • Administer LR or NS, avoid dextrose containing fluids
  • Continuous cardiac monitoring.

BP goals

(after adequate sedation and analgesia)

    • Prehospital: SBP <220 and DBP <120
      • antihypertensives after 1x SBP >220 or DBP> 120
    • Interfacility: (confirmed by CT)
      • ICH: SBP 140-160
        • antihypertensives after 2x SBP >160
      • SAH: SBP 100-120
        • antihypertensives after 2x SBP >120

Management of hypertension

  • Labetalol: short-acting β-blocker, quick onset, anti-hypertensive agent
    • Indication:
      • Flight < 30 minutes
      • Initial therapy while preparing nicardipine drip
      • HR > 60
    • Contraindications: HR < 60
  • Nicardipine: short-acting, titrateable, calcium channel blocker (vasodilator)
    • Indication:
      • Flight longer than 30 minutes
      • HR <60.
      • SBP <100: turn drip off and give IV bolus of 250-500ml crystalloid
  • Nitrates or nitroprusside initiated by referring facility for hypertension should be discontinued for transport. hypertension will be managed following guidelines above.

Management of hypotension

  • Discuss threshold for utilization of vasopressors (and type) with medical control even if the patient is normotensive. If on anti-hypertensive infusion, consider titrating or stopping medication.
    • Prehospital: If two consecutive systolic BP < 100, fluid bolus 250-500ml increments, if no immediate contact available with medical control. In discussion with medical control, consider phenylephrine or norepinephrine for BP unresponsive to fluids.
    • Interfacility: For systolic BP < 100, consider fluids as above and discuss addition of vasopressors as above with medical control. Maintain normothermia.

Coagulopathy

Neurological:

  • Provide analgesia and sedation as needed
  • Maintain C-spine precautions if any suspicion of neck trauma
  • Transport with HOB at 30°
  • Avoid flexion/rotation of neck. Maintain neck and head midline
  • Avoid restrictive ETT taping
  • Recheck pupils and GCS frequently
  • Take care with interventions that may increase agitation leading to increased ICP (e.g. OG/NG unless clinically indicated)
  • Increased ICP management per Increased ICP Policy
    • Treat observed pupillary changes of 2 mm or more
    • Treat observed GCS decreases of 2 points or more
  • Monitor for and treat seizure activity (see seizure policy)

GI

  • Insert orogastric tube if indicated

GU

  • Consider foley catheter for interfacility transfers