View source for ALNW:Intracerebral hemorrhage

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=Principles of Management=
Controlling severe hypertension, which will extend the bleed, and providing adequate cerebral blood flow, to minimize the effects of local ischemia, requires a fine balance. Oxygenation, ventilation and circulation must be managed meticulously. While the ideal blood pressure to target is a subject to debate, expert medical opinion supports more aggressive blood pressure management.
Stabilization and Transport:

==Airway/Breathing==
*Administer O2 to maintain saturations > 94%
*[[Intubate]] for airway control and/or deteriorating neuro status
*Use normal respiratory rates and tidal volumes
*Maintain PaCO2 ~35-45 via ABG/I-stat (flights > 30 mins)

==Cardiovascular==
*Requires good working IV. If tenuous or patient unstable, 2 IVs recommended with LR or NS
*Administer LR or NS, avoid dextrose containing fluids
*Continuous cardiac monitoring.
===BP goals===
(after adequate sedation and analgesia)
**'''Prehospital:''' SBP <220 and DBP <120
***antihypertensives after 1x SBP >220 or DBP> 120
**'''Interfacility: (confirmed by CT)'''
***[[ICH]]: SBP 140-160
****antihypertensives after 2x SBP >160
***[[SAH]]: SBP 100-120
****antihypertensives after 2x SBP >120

===Management of hypertension===
*[[Labetalol]]: short-acting β-blocker, quick onset, anti-hypertensive agent
**Indication:
***Flight < 30 minutes
***Initial therapy while preparing [[nicardipine]] drip
***HR > 60
**Contraindications: HR < 60
*[[ALNW:Nicardipine|Nicardipine]]: short-acting, titrateable, calcium channel blocker (vasodilator)
**Indication:
***Flight longer than 30 minutes
***HR <60.
***SBP <100: turn drip off and give IV bolus of 250-500ml crystalloid
*[[Nitrates]] or [[nitroprusside]] initiated by referring facility for hypertension should be discontinued for transport. hypertension will be managed following guidelines above.

===Management of hypotension===
*Discuss threshold for utilization of vasopressors (and type) with medical control even if the patient is normotensive. If on anti-hypertensive infusion, consider titrating or stopping medication.
**Prehospital: If two consecutive systolic BP < 100, fluid bolus 250-500ml increments, if no immediate contact available with medical control. In discussion with medical control, consider [[phenylephrine]] or [[norepinephrine]] for BP unresponsive to fluids.
**Interfacility: For systolic BP < 100, consider fluids as above and discuss addition of vasopressors as above with medical control. Maintain normothermia.

===Coagulopathy===
*Consider [[FFP]] and [[Vitamin K]] (IFT) if patient is excessively anti-coagulated( INR > 1.5, patient on [[ASA]] or [[clopidigrel]]. Consult with [[Medical Control]].
*Consider [[platelets]] if [[platelet count]] < 100K. Consult with Medical Control.

==Neurological:==
*Provide analgesia and sedation as needed
**Analgesia: [[morphine]] or [[fentanyl]] IV incrementally for pain/ discomfort
**Sedation: [[lorazepam]] or [[midazolam]] IV incrementally for anxiety or sedation
*Maintain C-spine precautions if any suspicion of neck trauma
*Transport with HOB at 30°
*Avoid flexion/rotation of neck. Maintain neck and head midline
*Avoid restrictive ETT taping
*Recheck pupils and [[GCS]] frequently
*Take care with interventions that may increase agitation leading to increased ICP (e.g. OG/NG unless clinically indicated)
*Increased ICP management per [[Increased ICP (ALNW)|Increased ICP Policy]]
**Treat observed pupillary changes of 2 mm or more
**Treat observed [[GCS]] decreases of 2 points or more
*Monitor for and treat seizure activity (see [[Seizures - Adult (ALNW)|seizure policy]])

==GI==
*Insert orogastric tube if indicated

==GU==
*Consider foley catheter for interfacility transfers

[[Category:Admin]]