An 84 year old female with a past medical history of atrial fibrillation on coumadin presents to the emergency department with symptoms concerning for stroke. She was last known well five hours ago. There is no history of trauma, fevers, rashes, or recent travel.
Pertinent Physical Exam
Vital Signs: BP 170/90, HR 78, RR 18, BGL 130
General: AxOx2, family reporting increased confusion from baseline, GCS 14
MSK: 4/5 Strength in LLE, 5/5 otherwise
Neuro: Left upper and left lower extremity ataxia
NIHSS: 4
Diagnostics
A CT head showed right sided intracranial hemorrhage without mass effect or intraventricular hemorrhage.
Treatment Plan
Control the blood pressure
Reverse any coagulopathies
Maintain glucose limits
Regulate the temperature
Ensure seizure prophylaxis
Decrease intracranial pressure
Surgical intervention
Control the Blood Pressure:
The goal is to maintain the blood pressure less than 140/80. The INTERACT2 and ATTACH2 trials suggest that for those patients with ICH with GCS scores >7, lowering BP to 140/80 is not harmful and may be minimally beneficial). Use nicardipine or labetalol.
Reverse Any Coagulopathies:
Warfarin (Coumadin):
IV 4-factor PCC (K-centra) - 1500 u + Vit K 10 mg IV.
Recheck the INR within 15 minutes. If the INR is known, dose K-centra on INR level with a target INR of 1.5.
LMWH:
Protamine sulfate - max dose 50 mg, dependent on time from administration and particular LMWH
Dabigatran (pradaxa):
Idarucizumab (pradaxabind) - 5 g over 15-20 mins is best (can also use FEIBA or K-centra if unavailable)
Xa inhibitors (apixaban, rivaroxaban)
K-centra 50 u/kg up to 3,000 units
Antiplatelets (ASA, plavix):
Platelet transfusion at neurosurgery's discretion
DDAVP
Thrombocytopenia (<50,000)
Absolute indication, normal to transfuse if <100,000
Maintain Glucose Limits
Tight glucose control between 80 to 110 mg/dL is associated with improved outcomes with BGL < 70 and > 180 associated with hematoma expansion, increased edema, death, or severe disability. However, tight control is difficult and routinely results in hypoglycemia. Do not treat glucose between 70 - 180 mg/dL.
Regulate the Temperature
Treat febrile ICH patients to a core temperature below 37.5 - 38 °C.
Ensure Seizure Prophylaxis
Anticonvulsants are associated with worse clinical outcomes in ICH. Consider EEG to evaluate for sub-clincal seizures.
Decrease Intracranial Pressure
Elevate head of bed
Hypertonic saline is the treatment of choice (200 mL of 3% over 10 minutes)
23.4% is the best option for elevated ICP with active herniation - Have a norepinephrine drip at the bedside to treat bradycardia during administration
Mannitol is another acceptable option
Surgical intervention
Indications for surgical intervention are posterior fossa, intraventricular hemorrhage, and occasional supratentorial. Get your neurosurgeons involved early.
Daniel Brodmerkel, DO is a current first year resident at Stony Brook Emergency Medicine.
References:
Edited by Bassam Zahid, MD