What are the emergency and admission orders for managing an intracerebral hemorrhagic stroke, including recommended Pakistani brand‑name medications?

Emergency and Admission Management of Intracerebral Hemorrhage (ICH)

For hemorrhagic stroke (ICH), immediate blood pressure control to systolic <140 mmHg, reversal of any anticoagulation, and admission to a stroke unit or ICU with neurosurgical backup are the cornerstones of emergency management. 1

Emergency Department Management

Immediate Assessment and Stabilization

Airway and Vital Signs:

• Secure airway if Glasgow Coma Scale <8 or compromised airway/ventilation 2
• Maintain oxygen saturation ≥94% 2
• Correct hypotension and hypovolemia to maintain organ perfusion 2

Urgent Imaging:

• Non-contrast CT head immediately upon arrival—this is the single most critical diagnostic step 2, 1
• Do not delay imaging for any reason
• CT angiography (CTA) if considering macrovascular cause (aneurysm, AVM) in younger patients or atypical presentations 3

Blood Pressure Management (Critical First Hour)

Target: Systolic BP <140 mmHg within 1 hour 1, 4

This is one of the strongest evidence-based interventions to prevent hematoma expansion.

Pakistani Brand Names for BP Control:

• Labetalol (Trandate®, Labetol®): 10-20 mg IV bolus over 1-2 minutes, repeat every 10 minutes OR continuous infusion 2-8 mg/min
• Nicardipine (Cardene®): 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 5-15 minutes (max 15 mg/hr)
• Esmolol (Brevibloc®): 500 mcg/kg bolus, then 50-300 mcg/kg/min infusion
• Hydralazine (Apresoline®): 10-20 mg IV (use cautiously—can cause reflex tachycardia)

Avoid: Sublingual nifedipine (unpredictable BP drops), nitroprusside (increases intracranial pressure)

Reversal of Anticoagulation (Time-Critical)

For Warfarin (Coumadin®, Warfarin®):

• Prothrombin Complex Concentrate (PCC) (Prothromplex®, Beriplex®): 25-50 units/kg IV immediately 1, 5
• Vitamin K: 10 mg IV slow infusion 1
• Target INR <1.4 within 4 hours 1
• Avoid fresh frozen plasma as first-line (slower, less effective than PCC) 5

For Direct Oral Anticoagulants (DOACs):

• Dabigatran (Pradaxa®): Idarucizumab (Praxbind®) 5 g IV 1
• Rivaroxaban/Apixaban (Xarelto®/Eliquis®): PCC 50 units/kg IV 1
• Andexanet alfa if available (not commonly available in Pakistan)

For Antiplatelet Agents:

• Do NOT give platelet transfusions routinely—associated with worse outcomes 1, 3
• Only consider if urgent neurosurgery planned

Laboratory Tests (Do Not Delay Treatment)

• Complete blood count
• PT/INR, aPTT
• Basic metabolic panel (electrolytes, creatinine, glucose)
• Correct glucose <60 mg/dL immediately with IV dextrose 2
• Troponin, ECG 2

Seizure Management

Do NOT give prophylactic anti-seizure medications 3

If seizure occurs:

• Levetiracetam (Keppra®, Levera®): 1000-1500 mg IV loading dose 1
• Alternative: Phenytoin (Dilantin®, Eptoin®): 15-20 mg/kg IV at ≤50 mg/min

Admission Orders

Location

• Stroke unit or Neurocritical Care Unit (mandatory—reduces mortality) 2, 1, 3
• Neurosurgical consultation within first hour 1

Monitoring

• Continuous cardiac monitoring
• Neurological checks every 1 hour for first 24 hours (Glasgow Coma Scale, pupil size/reactivity, motor strength)
• Blood pressure monitoring every 15 minutes until stable at target, then hourly
• Strict intake/output

Blood Pressure Management (Continued)

• Maintain systolic BP 130-150 mmHg 1
• Continue IV antihypertensive infusion as needed
• Transition to oral agents when stable:
  • Amlodipine (Norvasc®, Amlopin®): 5-10 mg daily
  • Telmisartan (Micardis®, Telma®): 40-80 mg daily
  • Metoprolol (Lopressor®, Betaloc®): 25-50 mg twice daily

Venous Thromboembolism Prophylaxis

Intermittent pneumatic compression devices starting immediately 1, 3

Pharmacological prophylaxis:

• Start subcutaneous heparin or LMWH after 24-48 hours if hematoma stable on repeat CT 1
• Enoxaparin (Clexane®, Lovenox®): 40 mg SC daily
• Unfractionated heparin: 5000 units SC every 8-12 hours

Intracranial Pressure Management (If Needed)

Indications: Deteriorating consciousness, signs of herniation, hydrocephalus

• Head of bed elevation 30 degrees
• Mannitol (Osmitrol®): 0.25-1 g/kg IV bolus (avoid if hypotensive) 1
• Hypertonic saline (3% NaCl): 250 mL IV over 30 minutes 1
• External ventricular drain (EVD) if hydrocephalus present 1, 3

For intraventricular hemorrhage with hydrocephalus:

• EVD + intraventricular alteplase (tPA) 1 mg every 8 hours for up to 12 doses (strong evidence for improved outcomes) 3

Supportive Care Bundle

• NPO until swallow screen completed
• Nasogastric tube if unable to swallow safely
• Avoid fever (target temperature <37.5°C): Paracetamol (Panadol®, Calpol®) 650 mg every 6 hours 1
• Avoid hyperglycemia (target glucose 140-180 mg/dL): Insulin sliding scale 1
• Stool softeners: Lactulose (Duphalac®) 15-30 mL daily to prevent straining 1
• Proton pump inhibitor: Omeprazole (Losec®, Omez®) 20 mg daily (if high risk for stress ulcer) 1

Repeat Imaging

• Repeat non-contrast CT at 24 hours or sooner if neurological deterioration 1
• CTA if considering surgical intervention

Neurosurgical Intervention Considerations

Cerebellar hemorrhage >15 mL with neurological deterioration: Surgical evacuation 3

Supratentorial ICH: Minimally invasive surgery may be considered for lobar ICH 10-100 mL 3

Avoid routine craniotomy for supratentorial ICH 3

Common Pitfalls

1. Overly aggressive BP lowering causing cerebral hypoperfusion—target is <140 mmHg, not <120 mmHg
2. Delaying anticoagulation reversal while waiting for laboratory results—give PCC immediately if patient on warfarin
3. Giving platelet transfusions for antiplatelet-associated ICH (harmful) 1
4. Prophylactic anti-seizure medications (no benefit, potential harm) 3
5. Early withdrawal of care within 24 hours—prognosis assessment should wait until after acute phase 1
6. Admitting to general medical ward instead of stroke unit (significantly worse outcomes) 2, 3

Secondary Prevention (Before Discharge)

• High-intensity statin: Atorvastatin (Lipitor®, Atorva®) 40-80 mg daily 2
• Blood pressure control target <130/80 mmHg long-term 2
• Rehabilitation referral (physical, occupational, speech therapy) 1