Diagnosis: Hypertensive Intracerebral Hemorrhage

A CT scan of the patient's head revealed a left basal ganglia hemorrhage with intraventricular extension causing midline shift due to early cerebral edema. 

Soon after viewing the CT scan findings the patient began to develop bilateral extensor posturing. Pupils continued to be equal and reactive. A dose of IV mannitol was delivered followed by intubation after pre-medication with IV lidocaine. The patient was hyperventilated to a goal PCO2 <35. Neurosurgery was consulted for emergent placement of an endoventricular device and the patient admitted to the neurological intensive care unit.

Subsequent CT angiogram of the patient's head revealed no evidence of an aneurysm or arteriovenous malformation. A urine toxicology screen was negative for cocaine or methamphetamine. Neurosurgery ultimately diagnosed the patient with a hypertensive intracerebral hemorrhage. It was later learned from the patient's family that she had a history of poorly controlled hypertension, hepatitis C, and regular IV heroin use for the past 5 years. 

ED MANAGEMENT OF ELEVATED INTRACRANIAL PRESSURE (ICP)

RAPID FIRE

Why we care

• Increased ICP --> cerebral herniation --> permanent disability and/or death

Intubation (patient is obtunded, not protecting airway, GCS <8) 

• Perform brief neuro exam before sedating/paralyzing
• Lidocaine 1.5-2 mg/kg IV push
• thought to blunt the increase in ICP due to stimulation of patient's airway 
• controversial, limited data/evidence to back efficacy
• Induction agent = Etomidate
• minimal cardiopulmonary disturbance = minimal ICP disturbance
• Paralytic agent = Succinylcholine (barring obvious contraindications)
• good for rapid onset
• some sources recommend pre-medicating with sub-paralytic dose of a nondepolarizing agent to mitigate fascinations and possible increase in ICP

Hyperventilation

• Goal is to reduce PCO2 to range of 30 - 35 mmHg 
• increases cerebral vasoconstriction --> reduced cerebral blood flow
• onset of effect in 30 sec, peak effect at 8 min
• thought to lower ICP by as much as 25% 

Osmotic Agents

• Mannitol (0.25-1 g/kg) = mainstay 
• reduces cerebral edema by osmotic gradient pulling water out of cells
• effect occurs within minutes; peak effect at 60 min
• lasts 6-8 hours
• Pros
• expands blood volume helping maintain systemic pressure
• promotes cerebral blood flow by reducing blood viscosity 
• free radical scavenger
• Cons 
• hypotension and renal failure in large doses
• increased bleeding into traumatic lesions by reducing hematoma tamponade

• Hypertonic Saline 
• used for increased ICP since 1919
• significantly reduces ICP
• encouraging data showing benefit of continuous infusion of 3% HTS in pediatrics
• Cons
• conflicting data regarding efficacy
• renal failure
• central pontine myelinolysis
• rebound increase in ICP

• Steroids do not lower ICP, some studies even suggest increased mortality

Emergent Neurosurgical Consult

• If patient not responding to above measures then may likely require:
• emergency burr holes (epidural hematoma)
• decompressive craniectomy (epidural hematoma) 
• endoventricular device (expanding intraventricular hemorrhage)

References: 

Heegaard WG, Biros MH, Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 41: Head Injury

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