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.

While 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.

Complete the CME activity.

Thanks to Walter Himmel and Scott Weingart for their contributions to the EM Cases podcast that inspired this article.

References

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