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Although not routinely indicated, consider hypertonic saline or mannitol based on ICP monitoring, point-of-care ultrasound optic nerve sheath diameter >6 mm, or clear signs of elevated ICP on brain imaging (not simply for low GCS).10,11 While there is no RCT evidence that hypertonic saline (3% 250 mL over 10 minutes) is superior to mannitol for controlling elevated ICP, it may be preferred because there are fewer concerns with sodium derangement and changes in hemodynamics. If you use mannitol, it is advisable to match urinary losses with normal saline administration to avoid hypotension.
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ACEP Now: Vol 37 – No 03 – March 2018While no single medical treatment has been shown to improve outcomes in ICH, if we avoid extremes of blood pressure, temperature, and glucose while minimizing spikes in ICP and rapidly reversing anticoagulants in the emergency department, we will give our ICH patients the greatest chance of a neurologically intact survival.
Thanks to Walter Himmel and Scott Weingart for their contributions to the EM Cases podcast that inspired this article.
References
- Specogna AV, Turin TC, Patten SB, et al. Factors associated with early deterioration after spontaneous intracerebral hemorrhage: a systematic review and meta-analysis. PLoS One. 2014;9(5):e96743.
- de Oliveira Manoel AL, Goffi A, Zampieri FG, et al. The critical care management of spontaneous intracranial hemorrhage: a contemporary review. Crit Care. 2016;20:272.
- Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.
- Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):1033-1043.
- Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelt therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613.
- Frontera JA, Lewin JJ 3rd, Rabinstein AA, et al. Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016;24(1):6-46.
- Passero S, Ciacci G, Ulivelli M. The influence of diabetes and hyperglycemia on clinical course after intracerebral hemorrhage. Neurology. 2003;61(10):1351-1356.
- NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
- Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-2060.
- Stevens RD, Shoykhet M, Cadena R. Emergency neurological life support: intracranial hypertension and herniation. Neurocrit Care. 2015;23(Suppl 2):S76-82.
- Raffiz M, Abdullah JM. Optic nerve sheath diameter measurement: a means of detecting raised ICP in adult traumatic and non-traumatic neurosurgical patients. Am J Emerg Med. 2017;35(1):150-153.
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