Hemorrhagic stroke
Revision as of 02:01, 20 December 2013 by Rossdonaldson1 (talk | contribs) (Rossdonaldson1 moved page Intracerebral Hemorrhage to Hemorrhagic Stroke)
Background
- ~10% of all acute strokes
- Warfarin use is significant risk factor
- Accounts for 5-15% of all cases
- Risk of ICH doubles for each 0.5 increase in INR above 4.5
Risk Factors
- HTN
- AVM
- Aneurysm
- Anticoagulant therapy
- Sympathomimetic drugs
- Intracranial tumors
- Amyloid angiopathy
- Smoking
Clinical Features
- Often clinically indistinguishable from SAH, ischemic stroke
- More likely to have rapidly progressive symptoms
- HA and N/V often precede the neurologic deficit
- Findings dictated by location of bleed (in order of most common)
- Putamen
- Thalamus
- Pons
- Cerebellum
Work-Up
- Head CT (non-con)
- Labs
- CBC
- Chem
- Coags
- T&S
- ECG
Management
- Elevating head of bed to 30 degrees (if pt not hypotensive)
- Blood pressure
- 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)
- SBP >200 or MAP >150
- Reverse coagulopathy
- Heparin
- Give protamine 1mg/100units of heparin based on time since last dose
- Warfarin
- Reverse regardless of INR
- Prothrombin complex concentrate 20-50mg/kg IV x1 OR
- FFP + vit K 10mg IV over 10min
- ASA/clopidogrel
- Desmopressin (0.3mcg/kg)
- Platelets
- Fondaparinux or Rivaroxaban
- rFVIIa 2mg (40 mcg/kg)
- Or PCC 25-50 U/kg
- Don't give both 2/2 to prothrombotic effects
- Dabigatran
- rFVIIa 100 mcg/kg
- Or PCC 25-50 U/kg
- Consider DDAVP 0.3 mcg/kg
- Hemodialysis, if feasible
- Heparin
See Also
Source
- Tintinalli
- EMcrit Podcast 17
- ebmedicine.net- Coag in ICH