This document presents a stabilization protocol for patients with hemorrhagic stroke during pre-hospital transport and upon arrival at the hospital. The goals are to prevent clinical decline and improve outcomes by protocolizing blood pressure management, warfarin reversal, use of mannitol for elevated intracranial pressure, appropriate oxygenation and ventilation, administration of antifibrinolytic and anti-seizure medications, and ensuring ultra-early transfer to a specialized stroke center. Key elements include transferring patients within 1 hour, maintaining systolic blood pressure below 140 mmHg, rapidly reversing elevated INR, administering mannitol or medications pre-transport if indicated, and monitoring for protocol adherence and patient outcomes.

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