What do I do for intracranial bleeding from projectile vomiting?

Management of Intracranial Bleeding Due to Projectile Vomiting

Immediate neuroimaging with CT or MRI is essential to assess the extent of intracranial bleeding from projectile vomiting, followed by prompt neurosurgical consultation and blood pressure control to a target systolic of 140-160 mmHg using IV nicardipine or labetalol.

Initial Assessment and Stabilization

• Airway, Breathing, Circulation:

  • Secure airway if GCS < 8 or deteriorating neurological status
  • Maintain adequate oxygenation (SpO2 > 94%)
  • Establish IV access for medication administration

• Neurological Assessment:

  • Perform rapid neurological examination using Glasgow Coma Scale
  • Document focal neurological deficits
  • Monitor for signs of increased intracranial pressure (declining consciousness, pupillary changes, Cushing's triad)

• Blood Pressure Management:

  • Target systolic BP 140-160 mmHg within 1 hour of initiating treatment 1
  • First-line agents: IV nicardipine or labetalol for smooth, titratable action
  • Avoid excessive BP reduction (>70 mmHg drop from baseline within 1 hour)
  • Avoid systolic BP <130 mmHg as it may worsen outcomes

Diagnostic Imaging

• Immediate CT or MRI brain to:
  • Confirm presence and extent of intracranial hemorrhage
  • Identify location (parenchymal, subarachnoid, subdural, epidural)
  • Assess for mass effect, midline shift, or hydrocephalus
  • Rule out other causes of bleeding (vascular malformations, tumors)

Management Based on Hemorrhage Type and Severity

For All Intracranial Hemorrhage Types:

1. Reverse Anticoagulation (if applicable):

   • For patients on vitamin K antagonists (warfarin) with INR ≥ 1.4:
     • Administer vitamin K 10 mg IV
     • Give prothrombin complex concentrate (PCC) based on INR and weight 2
   • For direct oral anticoagulants:
     • Idarucizumab 5g IV for dabigatran
     • Andexanet alfa for factor Xa inhibitors (apixaban, rivaroxaban)

2. Blood Pressure Control:

   • Use continuous arterial BP monitoring with transducer at level of tragus
   • Maintain systolic BP 140-160 mmHg 1
   • Avoid hypotonic solutions like Ringer's lactate in patients with severe head trauma 2

3. Intracranial Pressure Management:

   • Elevate head of bed to 30 degrees
   • If signs of increased ICP:
     • Consider mannitol 0.25-2 g/kg IV as a 15-25% solution over 30-60 minutes 3
     • Avoid corticosteroids for ICP management in ICH 1

Specific Management Based on Hemorrhage Type:

• Parenchymal Hemorrhage:

  • Small hemorrhages with minimal symptoms: conservative management with close monitoring
  • Large hemorrhages or significant mass effect: neurosurgical consultation for possible evacuation

• Cerebellar Hemorrhage >3 cm:

  • Surgical evacuation is recommended, especially if causing brainstem compression or hydrocephalus 1

• Intraventricular Hemorrhage with Hydrocephalus:

  • Consider external ventricular drainage, especially in patients with decreased level of consciousness 1

Monitoring and Prevention of Complications

• Neurological Monitoring:

  • Frequent neurological assessments using standardized scales (NIHSS, GCS)
  • Monitor for signs of deterioration that may indicate hematoma expansion

• Seizure Prophylaxis:

  • Consider in patients with lobar hemorrhages or with seizures at onset

• Thromboprophylaxis:

  • Apply intermittent pneumatic compression devices immediately
  • Consider pharmacological thromboprophylaxis 24-48 hours after bleeding has stabilized 1

• Prevention of Recurrence:

  • Identify and address underlying cause of projectile vomiting
  • Antiemetic therapy to prevent further episodes
  • Consider nasogastric tube for gastric decompression if persistent vomiting

Common Pitfalls and Caveats

• Delayed Deterioration: Hematoma expansion can occur within the first 24 hours after initial bleeding, requiring vigilant monitoring

• Misdiagnosis: Symptoms may be attributed solely to the cause of vomiting rather than recognizing the intracranial bleeding

• Inadequate Blood Pressure Control: Both hypertension and excessive BP reduction can worsen outcomes

• Neglecting Coagulopathy: Failure to identify and correct coagulation abnormalities can lead to hematoma expansion

• Inappropriate Fluid Management: Avoid hypotonic solutions in patients with intracranial hemorrhage 2

Follow-up Care

• Neurosurgical follow-up within 1-2 weeks
• Repeat imaging to assess resolution of hemorrhage
• Address underlying cause of projectile vomiting
• Gradual return to activities based on resolution of symptoms and imaging findings

Remember that early intervention is critical, as hematoma expansion typically occurs within the first few hours after the initial bleeding event and is associated with worse outcomes.