EM Educator Series: Not all head bleeds are alike – Spontaneous Intracerebral Hemorrhage

Authors: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. 

Case #1:

A 68-year-old male with a history of atrial fibrillation and hypertension presents with altered mental status. His wife found him on the couch groaning, unable to answer questions. His VS include RR 12, HR 82, BP 188/99, T 37C, and Sats 96%. His GCS is 10. CT demonstrates intracerebral hemorrhage.

Considerations:

1. What are the risk factors for spontaneous ICH?
2. What are the clinical presentations and four major locations?
3. What are your goals concerning management of blood pressure, serum glucose, and temperature?
4. What are your considerations regarding the airway? When should you intubate, what medications are preferred, and what should you use for post-intubation analgesia/sedation?
5. What should you consider for anticoagulation reversal?
6. How do you manage increased ICP in the setting of spontaneous ICH?
7. What can neurology and neurosurgery assist with? When should they be consulted?
8. Controversies: When is seizure prophylaxis needed? What about platelets?

Suggested Resources:

• Articles:
  • emDOCs – Critical Intracranial Hemorrhage: Pearls and Pitfalls in Evaluation and Management
  • LITFL – Intracerebral Haemorrhage
  • ALiEM – Update on the ED Management of Intracranial Hemorrhage: Not All Head Bleeds Are the Same
  • ALiEM – Podcast Follow-up: Interview with Dr. Debbie Yi Madhok, Co-Author of “Update on the ED Management of Intracranial Hemorrhage”
  • CORE EM – Intensive Blood Pressure Lowering in Intracerebral Hemorrhage (ATACH-2 Trial)
  • E.B.E.L. EM
    • Intensive Blood Pressure Control Doesn’t Benefit Patients with Acute Cerebral Hemorrhage (ATACH-2)
    • The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage?
  • Radiopaedia – Intracerebal Haemorrhage

• Podcasts:
  • EM Cases – Ep 104 Emergency Management of Intracerebral Hemorrhage – The Golden Hour