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Immediate priorities
Time zero stabilization
Airway protection triggers
GCS 8 or less
Loss of protective reflexes
Refractory hypoxemia or hypercapnia
Persistent vomiting with aspiration risk
Breathing targets
Oxygen saturation 94 to 98 percent
PaCO2 35 to 40 mmHg if no herniation
PaCO2 30 to 35 mmHg only as bridge for impending herniation
Circulation priorities
Two large bore IV lines
Cardiac monitoring
Temperature monitoring
Point of care glucose
Neurologic crisis triage
Herniation syndrome
Declining level of consciousness
Unilateral fixed dilated pupil
Extensor posturing
Cushing response
Immediate actions if herniation suspected
Head of bed 30 degrees
Neck midline
Hyperosmolar bolus selection
Hypertonic saline preferred if hypotension risk
Mannitol avoided if hypotension or renal failure risk
Emergent neurosurgery and neurocritical care activation
Imaging first pathway
Noncontrast CT head within minutes
ICH confirmed
CTA head and neck for selected patients
Coagulopathy reversal pathway parallel to imaging
ICH not confirmed
Ischemic stroke pathway
Mimic evaluation
Hemodynamic goals
Blood pressure strategy
Early controlled reduction to limit hematoma expansion
SBP 150 to 220 mmHg and no contraindication
Target SBP 140 mmHg
Maintenance SBP 130 to 150 mmHg
Avoid excessive lowering
SBP less than 130 mmHg association with harm in some cohorts
Preferred IV agents for rapid titration
Nicardipine infusion
Clevidipine infusion
Labetalol bolus
Intracranial pressure physiology
Cerebral perfusion pressure concept
CPP equals MAP minus ICP
Hypotension avoidance
ICP triggers for escalation
Clinical herniation signs
Hydrocephalus with IVH
Large hematoma with midline shift
Refractory agitation or ventilator dyssynchrony limiting care
Parallel process consults
Early team activation
Neurosurgery for all ICH with mass effect or IVH or posterior fossa
Cerebellar ICH concern
Brainstem compression
Obstructive hydrocephalus
ICH volume 15 mL or more
Neurocritical care
ICU level monitoring
EVD consideration for IVH with hydrocephalus
Hematology or thrombosis support
Complex anticoagulant reversal
Mechanical valve anticoagulation decisions
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.