Intracranial Hemorrhage (ICH) and Increased Intracranial Pressure (ICP) - Pathophysiology ICH Management: 1. Manage Blood Pressure • Spontaneous ICH and SAH BP target: < 140-160 • Avoid vasodilating agents (nitro-) because they increase cerebral blood volume and ICP 2. Neuroprotective Intubation • Before: +/- local lidocaine, +/- pre-treatment with Fentanyl 3mcg/kg then wait 3min, pre-ox (goal O2 >95%), paralysis + sedation • During: Minimize attempts, use glidescope • After: Minimize PEEP, EtCO2 35-40, Ensure adequate sedation 3. Address Coagulopathy • DOACs: Octaplex • Warfarin: Octaplex + Vitamin K • Heparin: Protamine Sulfate • If platelets < 100: consider platelet transfusion 4. Maintain Normals: Glucose, Temp 5. Manage ICP and Seizures if needed ICP Physiology: CO2: • Low CO2 = constricts BV = temporarily reduces ICP (but also reduces CPP) • High CO2 = dilated BV = raises ICP O2: • Hypoxia = dilated BV = raise ICP (dilates BV directly and via lactic acid formation) BP: • Hypotension = reactive dilated BV = raise ICP • Hypertension = potential expansion of bleed • CPP = MAP - ICP. Target MAP: 80. Why? Target CPP 60. High ICP: 20. Temp: • Increased metabolic demand = increased cerebral blood flow - raise ICP Osmotic Agents: • Osmotic agents = increase osmolarity of blood = water leaves brain cells Dr. Sarah Foohey @SarahFoohey #Intracranial #Hemorrhage #ICH #elevated #Intracranial #Pressure #ICP #Pathophysiology #neurology #neurosurgery #management
