hypertensive ICH

[basementbeastie]

anyone has trouble with intracranial bleeds and what service they should go to: neurosurgery versus neurology.......bleed is suspected to be from HTN, it is stable between two scans.....nobody wants them

neurosurg: nothing we gonna do
neuro: they have blood in their head

comments? 😕

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[basementbeastie]

also any comments are BP control in these cases.....used labetalol once recently -> got in trouble since "it doesn't really lower BP well".

used hydralazine once recently -> got in trouble since it lowers it too much!!

*CRAP*

 

[typhoonegator]

Many institutions have policies set between the neurology and neurosurgical services to make sure issues like this don't go unresolved. Small neurology services that are primarily consult-based and don't have access to a dedicated neuroICU might balk at these cases. I'm a neurology resident in Boston, and our neurology service takes deep hemorrhages like this one, which from your brief story sounds likely to be a hypertensive basal ganglia or thalamic bleed.

All these patients go to the neuroICU for at least 24 hours for high frequency neuro-checks and BP management. They should all get a-lines. For blood pressure management, we prefer labetalol acutely -- just keep doubling the IV push dose until you get it down. We don't like hydralazine because it is a venodilator and can raise ICP, although that is a general rule and ICP management shouldn't be an issue in this case. If the BP keeps jumping back up, we usually start a nicardipine gtt, but it usually is tough for the ED to get super quickly, and the ED nurses aren't usually very familiar with the dosing.

One last note, these small "classic hypertensive hemorrhages" can burn you sometimes, and we routinely get a CTA to ensure there isn't an AVM underlying the hemorrhage.

 

[ERMudPhud]

👍

Many institutions have policies set between the neurology and neurosurgical services to make sure issues like this don't go unresolved. Small neurology services that are primarily consult-based and don't have access to a dedicated neuroICU might balk at these cases. I'm a neurology resident in Boston, and our neurology service takes deep hemorrhages like this one, which from your brief story sounds likely to be a hypertensive basal ganglia or thalamic bleed.

All these patients go to the neuroICU for at least 24 hours for high frequency neuro-checks and BP management. They should all get a-lines. For blood pressure management, we prefer labetalol acutely -- just keep doubling the IV push dose until you get it down. We don't like hydralazine because it is a venodilator and can raise ICP, although that is a general rule and ICP management shouldn't be an issue in this case. If the BP keeps jumping back up, we usually start a nicardipine gtt, but it usually is tough for the ED to get super quickly, and the ED nurses aren't usually very familiar with the dosing.

One last note, these small "classic hypertensive hemorrhages" can burn you sometimes, and we routinely get a CTA to ensure there isn't an AVM underlying the hemorrhage.

👍 Thanks. What are you usually shooting for on the BP?

In the private world its usually a medicine ICU admit with neuro and neurosurg consulting. Labetalol works fine for BP its just that the range on the amount you have to give is quite wide. Hence the above advice on dosing

 

[typhoonegator]

The literature on the BP goals is...challenging. Also, neurosurgeons and neurologists typically give different answers. For the Nsurg guys, they are used to dealing with AVMs and aneurysmal bleeding, and they aim for SBP < 140 with a nice narrow pulse pressure. For hypertensive hemorrhage, this is likely overkill. Obviously, if they live at SBP 210, you don't want to bring them down that far anyway.

Typically I ask the ED for a goal SBP < 180 and DBP < 110. I don't think there is a lot of convincing literature for showing measurable improvement in outcomes/rebleeds for anything lower than that. But if I can get SBP below 160 with one agent, and they aren't going to infarct at that pressure, I'm all for that!

Obviously, if the bleed is big enough that mass effect and ICP are going to be an issue, we liberalize our goals to ensure a good CPP.

 

[membsr-8890]

Indication for neurosurg intervention = bleed dissecting into ventricles. Otherwise they're prob not going to do much, so maybe just send to neuro.

 

[kungfufishing]

Usually NSG looks first, and takes them if the patient has a problem they can solve. Otherwise Neurology. Ive had good success with Cardene or labetalol.

 

[totalbodypain]

I too try Neurosurg first then Neuro/MICU (No real inpt neurology service here). I have had pretty good luck with labetalol. Often these hypertensive bleeds also have a history of some cardiac issues and hydralazine can become somewhat contraindicated. I like the advice on dosing above.

 

[NinerNiner999]

I second the idea of obtaining a CTA when time allows. Often times this will clear up any questions between services. Labetalol has worked well...

 

[southerndoc]

Neurology and neurosurgery have a policy that any bleed must go to the neurosurgery service.

 

[VentdependenT]

Git yer hands on a nicardipine drip. Works like a champ. No increase in ICP like nitroglycerine/prusside. Easy to titrate. lowers heart rate a touch. Its a CCB, so you can leave it on in respect to preventing vasospasm.

 

[dchristismi]

I second the nicardipine drip. 🙂

At my institution, they all go to neurosurgery, who then generally consults the MICU intensivists (it's a closed ICU, with a weird loophole for neurosurgeons, but they generally prefer the critical care guys to manage). Neurology rarely is involved unless there are other issues. The problem we run into is that each neurosurgeon does things his own way and there's no predicting what he'll want.