Template:ICH Treatment: Difference between revisions
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===Reverse coagulopathy=== | ===Reverse coagulopathy=== | ||
*See [[anticoagulant reversal for life-threatening bleeds]] if on a known anticoagulant (e.g. heparin, coumadin, rivaroxaban) | *See [[anticoagulant reversal for life-threatening bleeds]] if on a known anticoagulant (e.g. [[heparin]], [[coumadin]], [[rivaroxaban]]) | ||
*[[Tranexamic acid]] 1g (if within 3 hours of event), followed by an additional 1g infused over 8 hours <ref>[[EBQ:CRASH-3 Trial|Crash-3 Trial]]</ref> | *[[Tranexamic acid]] 1g (if within 3 hours of event), followed by an additional 1g infused over 8 hours <ref>[[EBQ:CRASH-3 Trial|Crash-3 Trial]]</ref> | ||
====Antiplatelet==== | ====Antiplatelet Reversal==== | ||
''Includes [[aspirin]], [[prasugrel]], [[clopidogrel]]'' | |||
*Consider [[desmopressin]] (0.3mcg/kg) | *Consider [[desmopressin]] (0.3mcg/kg) | ||
*Transfusion of platelets has been shown to increase mortality [[EBQ:Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomized, open-label, phase 3 trial|(PATCH trial)]] | *Transfusion of platelets has been shown to increase mortality [[EBQ:Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomized, open-label, phase 3 trial|(PATCH trial)]] | ||
*In traumatic brain injury, platelet transfusion has been shown to reduce the degree of platelet inhibition, but no change in clinical outcomes<ref>Platelet Transfusion Does Not Improve Outcomes In Patients With Brain Injury On Antiplatelet Therapy Holzmacher, J.L., et al, Brain Injury 32(3):325, 2018</ref> | *In traumatic brain injury, platelet transfusion has been shown to reduce the degree of platelet inhibition, but no change in clinical outcomes<ref>Platelet Transfusion Does Not Improve Outcomes In Patients With Brain Injury On Antiplatelet Therapy Holzmacher, J.L., et al, Brain Injury 32(3):325, 2018</ref> | ||
* Consider platelet transfusion in patients with ICH for platelet count <50,000, but many hematologists and neurosurgeons recommend platelet transfusion for ICH with platelet count < 100,000 despite lack of evidence for improved outcomes, especially if the patient requires emergency surgery | * Consider platelet transfusion in patients with ICH for platelet count <50,000, but many hematologists and neurosurgeons recommend platelet transfusion for ICH with platelet count < 100,000 despite lack of evidence for improved outcomes, especially if the patient requires emergency surgery | ||
Revision as of 17:50, 22 June 2020
Elevating head of bed
- 30 degree elevation will help decrease ICP[1]
Seizure Prophylaxis and Treatment
- Prophylactic antiepileptics not recommended[2]
- Continuous EEG monitoring probably indicated in ICH patients with depressed mental status that is out of proportion fo degree of brain injury[3]
- Antiepileptics indicated for clinical seizures, seizures on EEG in patients with altered mental status[4]
Blood Pressure
- Few studies on optimal management however many guidelines recommending moderate reduction, often a goal systolic of 140-160's
- Rapid SBP lowering <140 has been advocated with early research showing improved functional outcome[5], but more recent work has found no difference between SBP <140 and <180[6]
- SBP >200 or MAP >150
- Consider aggressive reduction w/ continuous IV infusion
- SBP >180 or MAP >130 and evidence or suspicion of elevated ICP
- Consider reducing BP using intermittent or continuous IV meds to keep CPP >60-80
- SBP >180 or MAP >130 and NO evidence or suspicion of elevated ICP
- Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)
- Nicardipine in ICH: Start at 5mg/hr, increase 2.5mg q5min until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
- Labetalol in ICH: 20mg bolus over 1-2 minutes, repeat q3-5 mins until target blood pressure is achieved and then start an infusion of 1-8mg/min.
Reverse coagulopathy
- See anticoagulant reversal for life-threatening bleeds if on a known anticoagulant (e.g. heparin, coumadin, rivaroxaban)
- Tranexamic acid 1g (if within 3 hours of event), followed by an additional 1g infused over 8 hours [7]
Antiplatelet Reversal
Includes aspirin, prasugrel, clopidogrel
- Consider desmopressin (0.3mcg/kg)
- Transfusion of platelets has been shown to increase mortality (PATCH trial)
- In traumatic brain injury, platelet transfusion has been shown to reduce the degree of platelet inhibition, but no change in clinical outcomes[8]
- Consider platelet transfusion in patients with ICH for platelet count <50,000, but many hematologists and neurosurgeons recommend platelet transfusion for ICH with platelet count < 100,000 despite lack of evidence for improved outcomes, especially if the patient requires emergency surgery
- ↑ http://stroke.ahajournals.org/content/38/6/2001.full
- ↑ AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
- ↑ AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
- ↑ AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
- ↑ Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013; 368:2355-2365.
- ↑ Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016; 1-11. [Epub ahead of print].
- ↑ Crash-3 Trial
- ↑ Platelet Transfusion Does Not Improve Outcomes In Patients With Brain Injury On Antiplatelet Therapy Holzmacher, J.L., et al, Brain Injury 32(3):325, 2018