›Labetalol IV
›10 to 20 mg IV bolus over 2 minutes
›Repeat every 10 minutes as needed
›Maximum cumulative 300 mg
›Infusion 2 mg/min if needed
›Titrate to SBP target
›Avoid in reactive airways disease or acute decompensated heart failure
›Warfarin reversal — INR 1.4 or above
›4-factor PCC — Kcentra
›25 to 50 units/kg IV based on INR and weight
›Maximum 5000 units
›Normalizes INR within minutes
›Vitamin K IV
›10 mg slow IV infusion
›Prevents INR rebound over hours
›Repeat INR 30 minutes post-PCC — re-dose if INR above 1.4
›Dabigatran reversal
›Idarucizumab 5 g IV
›2.5 g IV over 5 to 10 minutes, repeat second dose
›Complete reversal within minutes
›Class I recommendation
›If idarucizumab unavailable
›aPCC 50 to 80 units/kg IV
›Dialysis removes dabigatran — consider in renal failure
›Factor Xa inhibitor reversal
›4-factor PCC
›25 to 50 units/kg IV
›Best available option in U.S. after andexanet alfa withdrawal
›aPCC 50 to 80 units/kg IV as alternative
›Timing and last dose critical — within 12 to 24 hours of last dose most effective
›Heparin reversal
›Protamine sulfate
›1 mg per 100 units heparin administered in preceding 2 to 3 hours
›Maximum 50 mg slow IV
›LMWH — partial reversal with protamine
›1 mg protamine per 1 mg enoxaparin; max 50 mg
Intracranial pressure management
›Hyperosmolar therapy
›Mannitol 20%
›0.25 to 1 g/kg IV bolus
›Repeat every 4 to 6 hours as needed
›Target serum osmolality below 320 mOsm/kg
›Hypertonic saline
›3% NaCl 250 mL IV over 30 minutes
›23.4% NaCl 30 mL IV for herniation emergency
›Target serum sodium 145 to 155 mmol/l in severe ICP
›Hypertonic saline may be preferred over mannitol in hypovolemic patients
›Head of bed elevation
›30 degrees — reduces ICP without compromising CPP
›Avoid head turns and neck compression
›Sedation for elevated ICP
›Propofol infusion
›5 to 50 mcg/kg/min IV
›Reduces CMRO2 and ICP
›Fentanyl for analgesia
›25 to 100 mcg IV PRN for painful stimuli
›Blunts ICP spikes during care
›No prophylactic antiseizure medications
›Not recommended — AHA/ASA Class III recommendation
›Treat only clinical or electrographic seizures
›Continuous EEG monitoring
›Recommended for depressed consciousness — AHA/ASA
›Subclinical seizures in 30% of patients with depressed GCS
›EEG monitoring duration individualized
›Acute seizure treatment
›Lorazepam 0.1 mg/kg IV for active seizure
›Maximum 4 mg per dose
›Repeat once if no response within 5 minutes
›Levetiracetam for maintenance if seizure occurred
›1000 to 1500 mg IV twice daily
›Preferred — no significant drug interactions
›Glucose control
›Target 7.8 to 10 mmol/l
›Hypoglycemia equally harmful — avoid
›Insulin infusion if persistently above 10 mmol/l
›Temperature control — normothermia
›Paracetamol 1 g IV every 6 hours for fever
›Avoid NSAIDs — platelet effect
›Active cooling for refractory hyperthermia
›Target temperature 36 to 37.5 degrees Celsius
›DVT prophylaxis
›Intermittent pneumatic compression — start day of diagnosis
›Graduated compression stockings alone not effective
›Pharmacological prophylaxis — start 48 to 96 hours after onset
›Once CT documents hemorrhage stability
›LMWH or UFH subcutaneous
›Class IIb recommendation
›Early dysphagia screening before oral intake
›Speech language pathology referral
›Aspiration pneumonia prevention
›NPO until screened
›Mobility
›Avoid aggressive mobilization within first 24 hours
›Associated with worsened 14-day mortality
›Rehabilitation activities may begin 24 to 48 hours after moderate ICH
›Stretching and functional task training
›Cerebellar hemorrhage
›Surgical evacuation plus or minus EVD
›Hematoma over 3 cm or over 15 mL with deterioration
›Brainstem compression or hydrocephalus
›Class I AHA/ASA recommendation
›Supratentorial ICH
›Minimally invasive surgery — MIS
›Volume over 20 to 30 mL with GCS 5 to 12
›Reduces mortality; functional outcome benefit uncertain
›Class IIb AHA/ASA recommendation
›Conventional craniotomy
›Not clearly beneficial for most supratentorial ICH
›Consider for accessible superficial hematomas with mass effect
›External ventricular drain
›IVH with obstructive hydrocephalus
›May combine with thrombolytic irrigation