This is a test page for Airlift Northwest please contact Dan Ostermayer or Andrew Mason with questions
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:
- 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)
- 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.
(after adequate sedation and analgesia)
Management of hypertension
- Labetalol: short-acting β-blocker, quick onset, anti-hypertensive agent
- Flight < 30 minutes
- Initial therapy while preparing nicardipine drip
- HR > 60
- Contraindications: HR < 60
- Nicardipine: short-acting, titrateable, calcium channel blocker (vasodilator)
- 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.
- 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.
- Provide analgesia and sedation as needed
- 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 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 seizure policy)
- Insert orogastric tube if indicated
- Consider foley catheter for interfacility transfers