The patient: Stroke notification
Sudden AMS at outside clinic, became acutely unresponsive/obtunded
Maybe he had a headache prior to onset? (history limited)
GCS 3 to 4 (E-1, V-1, M-3 to 2)
Afib on xaralto
HR 82, BP 196/87, RR 12, O2 sat 96% on NRB
PEARRL 3mm bilaterally
Flexor posturing, no seizure activity
Vomited 6 times prior to arrival and with EMS
It’s hard to come up with much else on your differential at this point except an ICH. You can go ahead and further specify either epidural, subdural, subarachnoid or intracerebral hemorrhage. But blood is clearly going somewhere bad.
Intubate vs Head CT
I always want to get the CT first as it has the critical info to get them to the OR. But often they are going to be seizing, posturing, or vomiting (as was our case). So, in these cases, intubation comes first.
How Do You Intubate?
Bed at 30 degrees always to prevent any spike ICP.
Avoid hypoxemia and hypotension at all cost. If it means a more experienced individual from your team, this is the case that needs it. I will not forget a similar case from residency when my attending told me I had 30 seconds max to get the tube in. “This better be your best ever tube”. No pressure.
You might hear about fentanyl pretreatment (3-5 mcg/kg), but this is 3 minutes before intubation. I’d rather not integrate another delay in getting this patient stabilized and to the scanner.
Hyperventilate (20 breaths/min, target PCO2 30-35) – sadly only a very brief temporizing measure. After 6 hours, the bicarbonate level will start to adjust to normalize the pH and limit further effect on the cerebral blood flow.
As you set up to intubate, ask the nurses to get a nicardipine or labetalol drip started. By this point the BP was climbing to 214/74. Ideally you want a target BP 140-160. Be careful though because without an arterial line in place, you are at risk for overshooting the target BP. I’d probably be happy just SBP<180 as we stabilize for the scanner.
We can talk about all the trials you want (INTERACT2 and ATTACH2) but those are much more stable patients (GCS>7). In this case, we have reason and need to act fast on BP.
Xaralto, Warfarin and Platelets
Order what you need based on history and your clinical exam. These drugs don’t come quickly.
If you suspect a bleed, it is reasonable to give 1,500 U 4-factor PCC* based on your history/exam.
*This is based on life-threatening ICH/bleed as was in this case.
Xaralto and other Xa inhibitors
4-factor PCC (Kcentra) 50 IU/kg [max 3,000 IU
10 mg IV Vitamin K (50 mL) over 10 minutes while your INR is pending.
And add 1,500 IU 4-factor PCC.
Repeat your INR 15 min later. Target INR 1.5
Transfuse platelets < 50k.
In truth, you will transfuse < 100k as NSGY is usually planning for the OR.
Our patient’s posturing changed from flexor (decorticate) to extensor (decerebrate). Go ahead and call NSGY without a CT. Tell them you are rolling to the scanner and are concerned about ICH and herniation. The patient will need them; we can take the grief they will give us. Do it for the patient.
Give hypertonic saline 3% 250cc over 10 minutes
Mannitol is an alternative but somewhat less preferred here.
What about Post-thrombolytic ICH?
Not this case, but we use plenty of t-PA at our shop for the risk to be real.
Crappy evidence for managing these patients, so just say your prayers.
Cryoprecipitate 10 units OR TXA (10-15 mg/kg) over 20 minutes.
Probably would go for cryo first as there are more theoretical risks of thrombosis with TXA.
A Word on Cushing’s Reflex
Interns, you might notice the patient didn’t seem to initially have all the vital signs suggestive of increased ICP. (1) Bradycardia, (2) Hypertension, (3) Respiratory depression. Not to worry though, within 2 hours his HR was 38!
Happy learning and hit me up with any questions 🙂
I attached a good review article on the management of ICH patients.