From the Guidelines
Management of intracranial hemorrhage (ICH) in the emergency department requires immediate stabilization, rapid diagnosis, and targeted interventions to prioritize morbidity, mortality, and quality of life as the primary outcome. The first step is to secure the airway, breathing, and circulation, with intubation indicated for patients with GCS <8 or declining mental status.
- Obtain an immediate non-contrast CT scan to identify the hemorrhage type, location, and size.
- Control blood pressure with IV medications such as labetalol (10-20 mg IV bolus, repeat every 10 minutes) or nicardipine (5 mg/hr, titrate by 2.5 mg/hr every 5-15 minutes) to maintain systolic BP between 140-160 mmHg for most ICH patients, as recommended by the American Heart Association/American Stroke Association guidelines 1.
- Reverse anticoagulation immediately if the patient is on blood thinners: for warfarin, administer 4-factor PCC (25-50 units/kg) and vitamin K (10 mg IV); for DOACs, give specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors.
- Manage increased intracranial pressure with head elevation to 30 degrees, mild hyperventilation (PaCO2 30-35 mmHg), and hyperosmolar therapy with mannitol (0.5-1 g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr), although the European Stroke Organisation guidelines found no apparent benefits of glycerol or mannitol in improving outcomes in ICH patients 1.
- Treat seizures with levetiracetam (1000 mg IV loading dose, then 500 mg IV twice daily) or fosphenytoin (20 mg PE/kg IV loading dose).
- Maintain normothermia, normoglycemia, and consult neurosurgery immediately, as the American Heart Association/American Stroke Association guidelines emphasize the importance of early and aggressive care in improving outcomes in ICH patients 1. The decision to use intracranial pressure monitoring should be based on the specific need to drain CSF in patients with hydrocephalus or "trapped ventricle" and the balance of monitoring risks with the unknown utility of ICP management in patients with ICH, as noted in the guidelines 1.
From the Research
Management of Intracranial Hemorrhage in the Emergency Department
The management of intracranial hemorrhage (ICH) in the emergency department (ED) involves several key steps, including:
- Rapid recognition and diagnosis of ICH, often using noncontrast CT examination of the brain 2
- Initiation of urgent therapy in the emergency room, such as stabilization of vital signs and prevention of further bleeding 3
- Neurosurgical consultation to pursue early surgical therapy, if necessary 3
- Admission to an intensive care unit (ICU) for close monitoring and management of patients with large hematomas or severe symptoms 4
Initial Management in the Emergency Department
Initial management of ICH in the ED may involve:
- Use of a resuscitative care unit to provide timely and appropriate critical care, and to decrease inpatient ICU utilization 5
- Rapid initiation of ICU-level care to alleviate the challenge of increasing emergency department boarding time of critically ill patients 5
- Discharge from the ED for patients with minor ICH, with close follow-up and monitoring for any signs of deterioration 5
Subtypes of Intracranial Hemorrhage
Different subtypes of ICH may require specialized management, including:
- Spontaneous intraparenchymal hemorrhage, often associated with hypertension 2
- Subarachnoid hemorrhage, which may require urgent surgical intervention 6
- Intraventricular hemorrhage, which may require management with ventricular drainage and other therapies 4
Goals of Management
The overall goal of management of ICH in the ED is to: