What is the emergency room management of a hypertensive intracerebral hemorrhage?

Emergency Room Management of Hypertensive Intracerebral Hemorrhage

Hypertensive intracerebral hemorrhage (ICH) is a medical emergency requiring immediate stabilization, rapid neuroimaging, and aggressive early management to reduce mortality and morbidity. 1

Initial Assessment and Stabilization

Airway, Breathing, Circulation (ABCs)

• Secure airway if GCS < 8 or declining respiratory status
• Provide ventilatory and cardiovascular support as needed
• Monitor vital signs closely, particularly blood pressure

Rapid Neurological Evaluation

• Perform baseline severity assessment using Glasgow Coma Scale (GCS) 1
• Document focal neurological deficits
• Monitor for early neurological deterioration (occurs in ~15% of patients within first hour of presentation) 1

Critical History Elements

• Time of symptom onset (or last known normal)
• Progression of symptoms
• Medication use (anticoagulants, antiplatelets, antihypertensives)
• History of hypertension, stroke, or bleeding disorders
• Recreational drug use (especially cocaine and sympathomimetics) 1

Immediate Diagnostic Workup

Neuroimaging

• Obtain non-contrast head CT immediately - gold standard for ICH diagnosis 1
• Consider CT angiography (CTA) to:
  • Identify patients at risk for hematoma expansion
  • Evaluate for underlying vascular abnormalities 1
• MRI is equally sensitive but may be impractical in emergency settings 1

Laboratory Studies

• Complete blood count, electrolytes, renal function
• Coagulation studies (PT/INR, aPTT)
• Cardiac-specific troponin (elevated troponin associated with worse outcomes) 1
• Toxicology screen if drug use suspected 1

Emergency Management Priorities

Blood Pressure Control

• Maintain systolic blood pressure < 160 mmHg to reduce risk of hematoma expansion 1
• For patients requiring IV antihypertensive therapy:
  • Nicardipine: Start at 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 15 minutes (maximum 15 mg/hr) 2
  • Monitor for hypotension; if it occurs, discontinue infusion and restart at lower dose when stabilized 2

Reversal of Coagulopathy

• For patients on vitamin K antagonists (VKA):
  • Administer vitamin K 5-10 mg IV
  • Provide prothrombin complex concentrates (PCCs) to rapidly correct INR 1
  • Target INR < 1.5 for emergency neurosurgery or invasive procedures 1
• For patients on other anticoagulants, follow specific reversal protocols

Management of Increased Intracranial Pressure (ICP)

• Elevate head of bed to 30 degrees
• In cases of cerebral herniation:
  • Consider osmotherapy (mannitol or hypertonic saline)
  • Temporary hyperventilation may be used while awaiting definitive treatment 1

Seizure Management

• Treat clinical seizures if they occur
• Prophylactic anticonvulsants are not routinely recommended

Neurosurgical Considerations

Urgent Neurosurgical Consultation

• Contact neurosurgery immediately for all ICH patients 1
• Expedite consultation for:
  • Large hematomas with mass effect
  • Cerebellar hemorrhages ≥ 3 cm
  • Hydrocephalus requiring ventricular drainage 3

Surgical Interventions

• External ventricular drainage for hydrocephalus
• Evacuation of large posterior fossa hematomas
• Decompressive surgery for patients with significant mass effect 1

Critical Care Transition

Disposition

• All ICH patients should be admitted to a neurocritical care unit or stroke unit 1
• If specialized units unavailable, arrange transfer to a tertiary care center 1

Critical Pathway Implementation

• Utilize standardized protocols for ICH management
• Ensure rapid communication between emergency department, neurology, neurosurgery, and critical care teams 1

Common Pitfalls to Avoid

• Delaying neuroimaging - CT should be performed immediately
• Excessive blood pressure reduction - may compromise cerebral perfusion
• Overlooking coagulopathy - rapid reversal is essential
• Failing to recognize early neurological deterioration - 28-38% of patients have hematoma expansion within first 3 hours 1
• Delaying neurosurgical consultation - early involvement improves outcomes

The high rate of early neurological deterioration following ICH underscores the need for aggressive early management and close monitoring in an appropriate critical care setting.