Announcements: Neuromuscular section updated with more questions.

  • Control BP: Goal SBP 100-140
  • Labetalol 10-20mg IV q1h prn OR Nicardipine drip (5 mg/hr increased by 2.5 mg/hr q15 minutes to max 15 mg/hr)
  • Arterial line placement while patient is in ED
  • Check BP q5mins x 1 hr then q15mins x 2hrs then q30mins
  • If patient is on Coumadin: INR goal <1.4:
    • STAT FFP: 10-20 ml/kg or 4-6 Units, if has CHF, give Lasix after infusion – send runner to blood bank
    • Vitamin K 10mg IV x 1 (slow push over 5 minutes) (takes 6 hrs to normalize INR), check PT/INR q6hrs
  • If patient is on Heparin gtt:
    • Protamine 1mg/100 Units if received heparin in last 3 hours.
    • Check PTT q1hr x 4 hrs then q4hrs
  • If patient is on Enoxaparin:
    • Protamine 1mg per 1mg of enoxaparin
    • Recheck PTT in 2-4 hrs; if still elevated consider giving additional 0.5mg of Protamine
  • If patient received IV tPA < 24 hrs ago then give (see reversal of t-PA protocol): Cryoprecipitate and Platelets
  • If patient is on Direct Thrombin Inhibitors (Argatroban, Lepirudin, Bivalirudin, Dabigatran): There is no specific antidote for these drugs at this time
  • Von Willebrand syndrome: Treat with 0.3 mcg/kg DDAVP over 30 min
  • If platelets are < 100k, transfuse platelets
  • No need for prophylactic AEDs. No indication for steroids. Osmotic therapy only if significant edema is present and patient exam compromised.
  • No data for platelet transfusion if patient was on ASA, Plavix or NSAIDs (but is often given by neurosurgery). May restart antiplatelets in one week after ICH
  • DVT/PE prophylaxis: on admission place patient on SCDs. Patients with DVT/PE may need to get IVC filter. May start prophylaxis SQ Heparin/LMWH 48 hours post-ICH
  • Consult neurosurgery (370 4492) if warranted
  • Repeat Head CT in 6 hrs or STAT PRN change in neurological exam
  • Neurochecks q1hrs, HOB 30 degrees

ICH Volume estimation = (A x B x C) / 2

A = longest diameter        
B = diameter perpendicular to A
C = number of slices multiplied by slice  thickness in cm


Adopted from

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