Ep 104 Emergency Management of Intracerebral Hemorrhage – The Golden Hour

This is EM Cases Episode 104 - Emergency Management of Intracerebral Hemorrhage - The Golden Hour with Scott Weingart and Walter Himmel. With special guest appearances by Rob Simard and Peter Brindley. There exists a kind of self-fulfilling prognostic pessimism when it comes to ICH. And this pessimism sometimes leads to less than optimal care in patients who otherwise might have had a reasonably good outcome if they were managed aggressively. Despite the poor prognosis of these patients overall, there is some evidence to suggest that early aggressive medical management may improve outcomes. As such, the skill with which you manage your patient with ICH in those first few hours could be the most important determinant of their outcome. In this Golden Hour you have a chance to prevent hematoma expansion, stabilize intracerebral perfusion and give your patient the best chance of survival with neurologic recovery. In this podcast, the Weingart-Himmel Sessions Redux, we answer questions such as: Should we attempt to manage blood pressure before ICH is confirmed on CT? What are the best drugs to manage blood pressure in ICH? What is the role of POCUS in emergency management of intracerebral hemorrhage? How do we best reverse the effects of anticoagulants and lytics in ICH patients? Are prophylactic antiepileptic drugs ever indicated in ICH in the ED? How do we best risk stratify patients with ICH? What are the indications for neurosurgical intervention? How do we determine if a patient with ICH has elevated ICP and how do we best manage it in the ED? What are the key elements of a neuro-critical care intubation? What is the preferred hyperosmolar agent for elevated ICP? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman December, 2017 Cite this podcast as: Helman, A, Weingart, S, Himmel, W, Simard, R, Brindley, P. Emergency Management of Intracerebral Hemorrhage - The Golden Hour. Emergency Medicine Cases. December, 2017. https://emergencymedicinecases.com/intracerebral-hemorrhage-golden-hour/. Accessed [date]. Can intracerebral hemorrhage vs ischemic stroke be predicted accurately before CT? Clinical findings that significantly increase the probability of ICH include altered level of awareness, neck stiffness, seizures, DBP>110, bilateral neurologic findings, vomiting and headache. However, no combination of clinical findings can be absolutely diagnostic. POCUS transcranial doppler and optic nerve sheath diameter may help increase your suspicion for ICH in the setting of abrupt onset neurologic symptoms. Raised ICP is more in keeping with ICH than with ischemic stroke. An optic nerve sheath diameter of >6 mm is highly specific for raised ICP while an optic nerve sheath diameter of <5 mm is highly sensitive for ruling out raised ICP. Transcranial doppler is able to detect both emboli and stenosis of the MCA helping to rule in an ischemic stroke. It can also help predict midline shift from ICH, as well as sometimes identify an ICH lesion. More evidence and experience with transcranial doppler is needed to determine its role in the workup of ICH. ICH management considerations before CT Patients with ICH who you deem at risk for aspiration (nausea, retching, vomiting, low GCS, apneic, herniating etc) should be considered for airway control before CT (see airway management below). For the patient who presents with stroke symptoms within a few hours of onset, whether you consider them more likely to have ICH vs an...