Transcript Management of Spontaneous ICH

Management of Spontaneous
ICH
Corey Heitz, MD
Director, Undergrad Med Ed
Assistant Professor, Emergency
Medicine
Disclosures
none
Objectives
Become familiar with 2015 ICH guidelines
Discuss evidence basis for main
recommendations
Provide initial management to ICH pts
I take
coumadin
What are the questions?
Best imaging
Blood pressure control
Seizure prophylaxis
Stop the bleeding
Evacuation/drainage
Imaging
CT and MRI are equally sensitive
(I, A)
MRI is better for subacute
blood
CTA/MRA/venography (IIb, B)
SAH
Calcifications at margins
Venous hyperattenuation
Unusual shape
Edema out of proportion
Lobar hemorrhage
<55yo
No history of htn
What are the questions?
Best imaging
Blood pressure control
Seizure prophylaxis
Stop the bleeding
Evacuation/drainage
Blood Pressure Control
Lowering BP to 140mmHg is safe (I, A)
Lowering BP to 140mmHg may improve functional
outcomes (IIb, C)
If >220mmHg, IV infusion may be effective (IIb, C)
What drug?
What are the questions?
Best imaging
Blood pressure control
Seizure prophylaxis
Stop the bleeding
Evacuation/drainage
I’m having a seizure!!
Seizure management
Treat seizures (I, A)
Treat patients with AMS and EEG positive (I, C)
Continuous EEG probably recommended if AMS
out of proportion to ICH (IIa, C)
Do not prophylax (III, B)
What are the questions?
Best imaging
Blood pressure control
Seizure prophylaxis
Stop the bleeding
Evacuation/drainage
Stop the bleeding!
Replace factors and/or platelets (I, C)
Hold VKA, give IV vit K, correct INR (I,C)
PCCs are faster and fewer side effects (IIb, B)
rFVIIa not recommended (III, C)
Stop the bleeding!
NOACs: PCCs or rFVIIa are options (IIb, C)
Activated charcoal if <2 hrs since last dose (IIb,
C)
Protamine if on heparin (IIb, C)
Use of platelets unclear if using antiplatelets
What are the questions?
Best imaging
Blood pressure control
Seizure prophylaxis
Stop the bleeding
Evacuation/drainage
Evacuation/Drainage
Hydrocephalus with AMS (IIb, B)
GCS <8, herniation, significant IVH
Cerebellar bleeds w herniation, decompensation
need surgery (I, B)
Early evac not better than waiting for decomp (IIb,
A)
What are the questions?
Best imaging
Blood pressure control
Seizure prophylaxis
Stop the bleeding
Evacuation/drainage
Others
• Swallow studies should be performed
• Initial severity scale (NIHSS or other; I, B)
• Avoid hyper/hypoglycemia
• No role for corticosteroids
Control BP
No seizure meds
Reverse INR
Initial severity
Swallow screen
Admit to ICU/neuro unit