Ep 104 Emergency Management of Intracerebral Hemorrhage – The Golden Hour [Link is to the podcast and show notes.] Dec, 2017 from Emergency Medicine Cases.
The above is simply an outstanding podcast and show notes.
At the very end of the show notes, Dr. Helman states that the best article on ICH management is The critical care management of spontaneous intracranial hemorrhage: a contemporary review [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Crit Care. 2016 Sep 18;20:272. doi: 10.1186/s13054-016-1432-0
Here is the Intro to the podcast and show notes:
This is EM Cases Episode 104 – Emergency Management of Intracerebral Hemorrhage – The Golden Hour with Scott Weingart and Walter Himmel. With special guest appearances by Rob Simard and Peter Brindley.
There exists a kind of self-fulfilling prognostic pessimism when it comes to ICH. And this pessimism sometimes leads to less than optimal care in patients who otherwise might have had a reasonably good outcome if they were managed aggressively. Despite the poor prognosis of these patients overall, there is some evidence to suggest that early aggressive medical management may improve outcomes. As such, the skill with which you manage your patient with ICH in those first few hours could be the most important determinant of their outcome. In this Golden Hour you have a chance to prevent hematoma expansion, stabilize intracerebral perfusion and give your patient the best chance of survival with neurologic recovery. In this podcast, the Weingart-Himmel Sessions Redux, we answer questions such as: Should we attempt to manage blood pressure before ICH is confirmed on CT? What are the best drugs to manage blood pressure in ICH? What is the role of POCUS in emergency management of intracerebral hemorrhage? How do we best reverse the effects of anticoagulants and lytics in ICH patients? Are prophylactic antiepileptic drugs ever indicated in ICH in the ED? How do we best risk stratify patients with ICH? What are the indications for neurosurgical intervention? How do we determine if a patient with ICH has elevated ICP and how do we best manage it in the ED? What are the key elements of a neuro-critical care intubation? What is the preferred hyperosmolar agent for elevated ICP? and many more…
Here are just a few of the highlights – [note to myself: but just review the whole show notes as they are outstanding]:
Differential diagnosis of ICH (Intracerebral Hemorrghage)
While there is a long list of causes of ICH*, the most common causes of ICH include hypertension (which tend to cause deep brain basal ganglia, brain stem and cerebellar bleeds) and amyloid angiopathy** usually seen in elderly patients (which tend to cause large lobar bleeds).
*ICH (intracerebral hemorrhage) – Link is to the emedicine.medscape.com article Updated: Dec 07, 2018.
**Cerebral amyloid angiopathy – Link is to the emedicine.medscape.com article
It is important to identify two other important causes of ICH in the ED, coagulopathy associated ICH* and cerebral venous thrombosis**, as they require specific time-sensitive treatment.
*Coagulopathy associated ICH* – Diagnosis and Management of Coagulopathy-Related Intracerebral Hemorrhage [PubMed Abstract]. Link is to Semin Neurol. 2016 Jun;36(3):274-87. doi: 10.1055/s-0036-1582133. Epub 2016 May 23.
**Cerebral venous thrombosis – Link is to the emedicine.medscape.com article Updated: Oct 09, 2018.
**Cerebral venous thrombosis – Link is to Excerpts From And Links To 2011 AHA/ASA Scientific Statement On Cerebral Venous Thrombosis, Posted on April 23, 2019 by Tom Wade MD
The Big 6 considerations in medical management of ICH in the ED
- BP
- Coagulopathy
- Glucose
- Temperature
- Seizure activity
- ICP
Hypotension (MAP <75-80) should be avoided at all costs in patients with ICH.
The antihypertensive agents of choice in ICH are nicardipine or labetolol
Nicardipine is the antihypertensive agent of choice in ICH because it does not affect the ionotropy of the heart, and being a pure arterial vasodilator it has no significant effect on cerebral vasodilatation or venous dilatation.
Dosing nicardipine in ICH: Start nicardipine at 5mg/hr and increase q5min by 2.5mg until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
Management of elevated intracranial pressure (ICP) in intracerebral hemorrhage
ED ICP management strategies include:
- Head of the bed elevation between 30 and 45° with the head kept midline
- Appropriate analgesia and sedation
- Normocapneic ventilation or hyperventilation if herniating
- Hypertonic solutions (e.g. hypertonic saline or mannitol)
The best article on ICH management is The critical care management of spontaneous intracranial hemorrhage:
a contemporary review [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Crit Care. 2016 Sep 18;20:272. doi: 10.1186/s13054-016-1432-0
Resources:
(1) Helman, A, Weingart, S, Himmel, W, Simard, R, Brindley, P. Emergency Management of Intracerebral Hemorrhage – The Golden Hour. Emergency Medicine Cases. https://emergencymedicinecases.com/intracerebral-hemorrhage-golden-hour/. Accessed [4-22-2019].
(2) The critical care management of spontaneous intracranial hemorrhage: a contemporary review [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Crit Care. 2016 Sep 18;20:272. doi: 10.1186/s13054-016-1432-0
