Template:ICH Treatment

Elevating head of bed

• 30 degree elevation will help decrease ICP

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)

Reverse coagulopathy

Heparin

• Give protamine 1mg/100units of heparin based on time since last dose

Warfarin

1. Stop warfarin
2. Give Vitamin K 5-10mg IV INR will decrease over 24-48 hours (small risk of anaphylaxis with IV Vitamin K)
3. Give 4 Factor prothrombin complex concentrate (PCC)
   • If no PCC, then give 15 ml/kg fresh frozen plasma (no benefit to combining PCC and FFP)

Antiplatelet

• Includes aspirin, prasagril, clopidogrel
• Consider Desmopressin (0.3mcg/kg)
• Transfusion of platelets has been shown to increase mortality

Fondaparinux or Rivaroxaban

• rFVIIa 2mg (40 mcg/kg)
• Or PCC 25-50 U/kg
• Don't give both 2/2 to prothrombotic effects

Dabigatran

• Idarucizumab (Praxbind): 5 grams IV (approved as of October 2015)
• rFVIIa 100 mcg/kg
• Or PCC 25-50 U/kg
• Consider DDAVP 0.3 mcg/kg
• Hemodialysis, if feasible