What is the management of intracranial bleeding in the emergency room?

From the Guidelines

Management of intracranial bleeding in the emergency room requires immediate stabilization, rapid diagnosis, and prompt intervention, with the most critical step being to secure the airway, ensure adequate breathing, and maintain circulation with a target systolic blood pressure of 140-160 mmHg to balance cerebral perfusion while minimizing bleeding. The first step is to obtain an urgent non-contrast CT scan of the head to identify the type, location, and extent of bleeding.

• Reverse anticoagulation if present: for warfarin, administer vitamin K 10 mg IV and prothrombin complex concentrate (25-50 units/kg) as recommended by recent guidelines 1, which have shown that prothrombin complex concentrate (PCC) is preferred over fresh frozen plasma (FFP) for warfarin reversal due to its faster onset of action, lower risk of adverse reactions, and no need for ABO compatibility.
• For direct oral anticoagulants, use specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors.
• Control seizures with benzodiazepines (lorazepam 4 mg IV or diazepam 10 mg IV) followed by levetiracetam 1000 mg IV or phenytoin 20 mg/kg IV if needed.
• Manage elevated intracranial pressure with head elevation to 30 degrees, mild hyperventilation (target PaCO2 30-35 mmHg), and osmotic therapy with mannitol 0.5-1 g/kg IV or hypertonic saline (3% NaCl) 250-500 mL over 30 minutes.
• Neurosurgical consultation is essential for potential surgical intervention, particularly for large hematomas, cerebellar hemorrhages, or those causing significant mass effect, as outcomes worsen with delayed treatment, and the first hours after intracranial bleeding represent the window of opportunity to prevent secondary brain injury from increased intracranial pressure, cerebral edema, and herniation, as supported by guidelines from the American Heart Association/American Stroke Association 1.

From the Research

Management of Intracranial Bleeding in the Emergency Room

The management of intracranial bleeding in the emergency room, particularly in patients on warfarin, is a critical issue that requires prompt and effective treatment. The following are key points to consider:

• Reversal of anticoagulation is essential in patients with intracranial hemorrhage on warfarin therapy 2, 3, 4.
• The use of prothrombin complex concentrate, fresh frozen plasma, and recombinant factor VIIa are options for reversing warfarin anticoagulation, with prothrombin complex concentrate being statistically significantly faster at correcting the INR compared to fresh frozen plasma transfusions 3, 4.
• Vitamin K is recommended to be used in addition to fresh frozen plasma or prothrombin complex concentrate to reverse warfarin-associated intracranial hemorrhage 4.
• The rate of intracranial bleeding in patients on warfarin is considerable, and loss of consciousness is associated with high rates of intracranial bleeding 5.
• A protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy can improve outcomes, including time to operative intervention 6.

Treatment Options

Treatment options for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage include:

• Prothrombin complex concentrate: statistically significantly faster at correcting the INR compared to fresh frozen plasma transfusions 4.
• Fresh frozen plasma: can be used in addition to vitamin K to reverse warfarin-associated intracranial hemorrhage 4.
• Recombinant factor VIIa: appears to rapidly reverse warfarin's effect on INR, but is not FDA-approved and is associated with a 5% thromboembolic event rate 4.
• Vitamin K: recommended to be used in addition to fresh frozen plasma or prothrombin complex concentrate to reverse warfarin-associated intracranial hemorrhage 4.

Clinical Considerations

Clinical considerations in the management of intracranial bleeding in the emergency room include:

• The need for prompt and effective treatment to prevent further bleeding and improve outcomes 2, 3, 4.
• The importance of reversing anticoagulation in patients with intracranial hemorrhage on warfarin therapy 2, 3, 4.
• The use of a protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy can improve outcomes, including time to operative intervention 6.