Template:ICH Treatment

Elevating head of bed

• 30 degree elevation will help decrease ICP

Seizure Prophylaxis

• For example: Keppra 1,000mg IV load

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, but more recent work has found no difference between SBP <140 and <180
• 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)

• Dosing nicardipine in ICH: Start nicardipine at 5mg/hr and increase q5min by 2.5mg until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
• Dosing labetolol in ICH: Start with labetolol 20mg over 1-2 minutes and then 20mg 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)

Antiplatelet

• Includes aspirin, prasagril, 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
• 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