›INR > 6: 50 units/kg IV (max 5000 units)
›Administer within minutes of decision
›Vitamin K IV
›10 mg IV slow infusion over 30 minutes
›Onset 6 to 12 hours for lasting INR correction
›Administer concurrent with PCC for durability
›Direct oral anticoagulant reversal
›Dabigatran: idarucizumab (Praxbind)
›5 g IV (two vials of 2.5 g) administered within minutes
›Class I recommendation for life-threatening bleeding
›Rivaroxaban, apixaban, edoxaban: andexanet alfa
›Low dose regimen 400 mg IV bolus then 480 mg infusion over 2 hours
›High dose regimen for rivaroxaban > 10 mg or apixaban > 5 mg within 8 hours: 800 mg bolus then 960 mg infusion
›4-PCC as alternative if andexanet alfa not available
›25 to 50 units/kg IV
›ACEP Level B recommendation
›Platelet transfusion
›Target platelet count >= 100 x 10^9/L in surgical candidates
›One apheresis platelet unit or six pooled units raises count 30 to 50 x 10^9/L
›Antiplatelet drug effect: platelet transfusion if symptomatic and on aspirin or clopidogrel
›Hyperosmolar therapy
›Mannitol 20% solution
›0.5 to 1 g/kg IV bolus over 15 to 20 minutes
›Onset 15 to 30 minutes, duration 3 to 6 hours
›Monitor serum osmolality: maximum 320 mOsm/kg
›Serum sodium and renal function monitoring
›Hypertonic saline 3%
›150 to 250 mL IV bolus over 15 to 20 minutes
›Target serum sodium 145 to 155 mmol/l
›Avoid rapid sodium correction > 10 mmol/l per 24 hours
›Hypertonic saline 23.4%
›30 mL IV for refractory herniation via central line only
›Fastest osmolar effect for herniation rescue
›Head positioning and general measures
›Head of bed 30 degrees neutral position
›Facilitates venous drainage and reduces ICP
›Avoid neck flexion or rotation
›Avoid hyperthermia: target normothermia <= 37.5 C
›Acetaminophen 1 g IV every 6 hours for fever
›Cooling blanket for refractory hyperthermia
›Avoid hypoxia and hypercapnia
›PaO2 > 80 mmHg
›PaCO2 35 to 40 mmHg except brief herniation rescue
›External ventricular drain
›Indicated for hydrocephalus with GCS decline
›Provides ICP monitoring and CSF diversion
›Drain at 10 to 15 cmH2O above external auditory canal
›Risk of ventriculitis 5 to 10% per insertion
›Lumbar drain contraindicated with mass effect or hydrocephalus
›Risk of downward herniation
›EVD preferred for IVH with hydrocephalus
›Acute seizure treatment
›Lorazepam IV first line
›0.1 mg/kg IV up to 4 mg per dose
›Repeat once after 5 minutes if seizure continues
›Levetiracetam IV loading dose for breakthrough or prophylaxis after clinical seizures
›1000 to 3000 mg IV over 15 minutes
›Maintenance 1000 mg IV every 12 hours
›Preferred over phenytoin for tolerability and interaction profile
›Phenytoin or fosphenytoin as second agent
›Fosphenytoin 20 mg PE/kg IV at maximum 150 mg PE/min
›BP and cardiac monitoring required during infusion
›Prophylactic anticonvulsant policy
›Routine prophylaxis not recommended per current guidelines
›No mortality benefit shown in randomized data
›Initiate only after clinical seizure confirmed
›Short-term use reasonable in high-risk locations
›Cortical AVM with lobar hematoma
›Duration limited to 7 days then reassess
Neuroprotective and supportive measures
›Glycemic management
›Target glucose 6 to 10 mmol/l
›Insulin infusion protocol for persistent hyperglycemia
›Hypoglycemia equally harmful: glucose < 4 mmol/l requires immediate correction
›Frequent glucose monitoring every 1 to 2 hours if insulin infusion
›DVT prophylaxis
›Sequential compression devices immediately post-admission
›Mechanical prophylaxis continued until ambulation
›Pharmacologic DVT prophylaxis timing individualized
›Generally 24 to 48 hours after surgical hemostasis or hemorrhage stability confirmed
›Hematology and neurosurgery joint decision
›Nutrition
›NPO acutely in all patients
›Potential for emergent surgery or intubation
›Swallow safety evaluation before oral intake
›Enteral nutrition via NGT for intubated patients
›Start within 24 to 48 hours of ICU admission if hemodynamically stable
›Standard polymeric formula at 25 kcal/kg/day