Hemorrhagic stroke transfer protocol

1. Pre- and inter-transport
stabilization protocol for
patients with
hemorrhagic stroke
Arun Ranganath MD
David Seder MD, FCCP
Maine Medical Center
Department of Critical Care Services

2. ICH/IVH Aneurysmal SAH

3. Why do we need a
stabilization protocol?
• Multiple episodes of patients declining or dying
between initial ED presentation and arrival at
MMC
– Rebleeding (SAH) due to rerupture of aneurysm
– Hematoma expansion due to inadequate BP control
or coagulopathy
– Uncal or transtentorial herniation due to inadequate
treatment of mass effect and lack of attention to ICP

4. Goals of the protocol
• Provide simple but highly effective tools for
managing the most common preventable
causes of clinical decline in the CRITICAL
FIRST HOURS OF MANAGEMENT
• Facilitate and decrease delays in transfer
• Improve the statewide outcomes of patients
with hemorrhagic stroke

5. Where do the recommendations
come from?

6. Stabilization Protocol - Summary
• Transfer of appropriate patients within 1 hour of
presentation
• Protocolized BP management
• Protocolized reversal of warfarin
• Pre-transport Mannitol in selected patients
exhibiting a mechanism of injury, imaging, and exam
consistent with elevated ICP
• Appropriate oxygenation and ventilation
• Aminocaproic acid load for nontraumatic SAH
• Fosphenytoin load for nontraumatic SAH

7. 1. Ultra-early transfer
• Rebleeding (SAH) and hematoma expansion
(ICH) are most likely in the very early hours after
a brain hemorrhage.
• Urgent surgical decompression, ventriculostomy
placement, and aneurysm repair save lives and
preserve neurological function.
• Dedicated care in a Neurological Intensive Care
Unit is associated with better patient outcomes.

8. 1. How to connect for transfer
• Call MMC REMIS at 207-662-6632
• SAH: Ask for Neurosurgery attending
• ICH/IVH: Ask for Critical Care Medicine
attending
• If there is no ICU bed and the patient is in
trouble – we will bring to the MMC ED

9. 2. Protocolized BP management
• ICH/IVH…or SAH!!
– Target SBP<140 mmHg within 20 minutes of
identifying bleed
– Nicardipine IV 5-15mg/hr – titrate q15m
– Labetalol IV 10-20mg IV push
– BP documentation q10 minutes
– Hydralazine is 3rd
line agent
• Do not allow hypotension

10. 3. Protocolized warfarin reversal
• Reverse INR if > 1.5
• Vitamin K 10mg IV push
• PCC (Profilnine or Kcentra) push –
depending on INR…see next slide
• Do not wait for FFP to transfer!

12. Why PCC and not FFP?
• FFP is ineffective at rapidly reversing the INR
– Type and cross, Defrost, Rate of infusion
= HOURS OF DELAY
– Rare that adequate amount of FFP is infused
– 35% reversed at 24h prior to new MMC protocol
• PCC highly effective at reversing INR with
few AEs
– Inject and go…

13. • MMC PCC
experience:
– Initiated protocol
in 2009
– 18 months WA-
ICH after
implementation
compared to 36
months prior
– In-hospital
mortality declined
(45.1% vs 18.2%,
P=0.013)
Clin Neurol Neurosurg 2013;115(6):770-4
Crit Care Med 2011;39:S518

14. 4. Pre-transport mannitol in
appropriate patients
• Large ICH with mass effect
• IVH with hydrocephalus
• SAH with hydrocephalus
• SAH with cerebral edema
• Any SAH with GCS<6
• Patients with a clinical exam suggesting
herniation

15. 4. Pre-transport mannitol in
patients with elevated ICP
• 1gm/kg administered as fast as possible
• Keep the head of the bed at 30-45 degrees
during transport
• DO NOT HYPOVENTILATE
• DO NOT ALLOW MAP<80 mmHg

16. Mass effect – give mannitol Hydrocephalus – give mannitol if
GCS<8 or rapid decline

17. 5. Appropriate oxygenation and
ventilation
• Keep the SpO2 > 94% but keep FiO2≤0.6
– Low (<60mmHg) and high (>300mmHg)
prehospital/ED PaO2 associated with WORSE
OUTCOMES
• Keep the ETCO2 between 30-40
– Hypoventilation causes increased ICP
– Hyperventilation causes decreased CBF
– Both are associated with WORSE OUTCOMES

18. 6. Aminocaproic Acid for SAH
• Antifibrinolytic agent
– Decreases bleeding, increases clotting
• Decreases rebleeding: 11.4% to 2.7%
• Criteria
– Age < 65
– No prior history of MI, stroke, DVT, or PE
• 4g IV load then infuse at 1gm/hr

19. Stroke. 2008;39:2617
Cumulative rebleeding-free survival
according to antifibrinolytic group
• Significant decrease in
rebleeding in EACA-treated
patients (2.7%) versus non-
EACA patients (11.4%).
• There was no difference in
ischemic complications
between cohorts.
• 8-fold increase in deep
venous thrombosis in the
EACA group but no increase
in pulmonary embolism.
• Nonsignificant 76%
reduction in mortality
attributable to rebleeding
• 13.3% increase in favorable
outcome in good-grade
EACA-treated patients and
6.8% increase in poor-grade
patients.

20. 7. Prophylactic fosphenytoin
load for SAH
• A seizure would cause a surge in BP and re-
rupture of the aneurysm
– 15mg/kg IV fosphenytoin over 15 minutes or
levitiracetam 1000mg IV push
• Not recommended for ICH/IVH prophylaxis
• Appropriate in ICH/IVH if seizures occur

21. A few reminders…
• Transport should not be delayed for these
stabilization measures
• Sometimes patients will need transport prior
to completion of the stabilization bundle
• The Dx is not always obvious, and not every
patient will fit neatly into the stabilization
protocols – they should serve as a guideline

22. What quality measures will we
track?
• Adherence to protocol
– Delays to transfer, and why they occurred
– Warfarin reversal
– Maintenance of BP goals in ED/Transport
vehicle/MMC /ICU prior to securing the aneurysm
– Appropriate use of osmotherapy
– Aminocaproic acid and fosphenytoin use
• Adverse events
• Outcomes

23. Closing the loop, sharing
ownership
• Good outcomes in hemorrhagic stroke
require an outstanding system of care – we are
all part of it
• We will report back quality metrics on transfer
cases to the referring and primary care
physicians
• We will report back the MMC experience,
AEs, and outcome at hospital discharge

24. Discussion