A 78 year old man on warfarin for atrial fibrillation develops a spontaneous weakness of his left hand and leg

and a deteriorating conscious state. he presents within 20 minutes of onset of symptoms and a CT scan confirms a right parietal intracerebral haemorrhage. Outline your medical management of this case. CICM Answer JFICM answer Specific features that would alter the management plan should be sought in the history (particularly of other drugs affecting coagulation eg aspirin, clopidogrel) and examination. Obviously attention should be paid to resuscitation(including airway management) if required and supportive care (including careful blood pressure control) but the predominant focus should be towards correction of coagulopathy. Spontaneous bleeds can occur at any (or no) levels of anticoagulation but rates increase significantly when the INR is above 4. The PT or INR and coagulation parameters should be measured urgently. Where there is clinical or neurological deterioration, reversal of anticoagulation should not be delayed for results. The full effect of vitamin K in reducing the INR takes up to 24 hours to develop, even when given in larger doses with the intention of full reversal. For immediate reversal of clinically significant bleeding, the combination of prothombin complex concentrates and FFP covers the period before Vit K has reached its full effect. Vitamin K is essential for sustaining the reversal achieved by a PCC and FFP approach. PCC is a three factor concentrate containing factors II, IX and X, but only low levels of factor VII. Therefore the adjunctive use of FFP should be administered as a source of factor VII. Treatment with recombinant factor VIIa within 4 hours of the onset of intracerebral haemorrhae has been reported to limit extension of the haematoma, reduce mortality and improve functional outcome. However rFVIIa treatment is associated with some increase in the frequency of thrombembolic adverse events.

Key issues: Time critical scenario Likely airway compromise Management of warfarin reversal

Management of IC bleed

Management General/ supportive

Rescuscitate ABC

Airway likely primary concern here Avoid secondary brain injury avoid hypoxia, hypotension, hypercapnoea, hypocapnoea, hypoglycaemia

Intubate if survivable haemorrhage and GCS < 10 or concern re: airway compromise.

Use neuroprotective strategy

Head up 30 degrees

Maintain CPP. Avoid pronounced fluctuations in BP.

Specific

Reversal of Anticoagulation follow MJA practice guidelines. Life threatening bleed = full reversal 50U/kg PTX, 10mg VitK , 300ml FFP

Management of ICH this is very likely to be a non-operative bleed and main strategy will be to avoid secondary insults. STICH trial suggests equivalent results from early conservative management.

Blood pressure management no definitive evidence to support practice. INTERACT suggests that early aggressive blood pressure control is not harmful and may reduce haematoma size. Treat extremes (SBP > 200mmHg, MAP > 130mmHg)

Neurology opinion stroke care unit will provide care post discharge from ICU

Neurosurgical opinion centre specific. Surgery not generally recommended in supratentorial bleeds unless within 1cm of surface

Novel therapies unfortunately phase III trials of activated factor VII for this indication have failed to demonstrate a clinical benefit (despite reducing haemorrhage volume)

Other

Information for family/ next of kin catastrophic event. Difficult to prognosticate but at least moderate disability likely

Standard ICU care stress ulcer prophylaxis appropriate, pressure care, DVT prophlylaxis to be withheld until stroke team approval, stress ulcer prohylaxis and normoglycaemia appropriate

Summary: Neurological emergency Warfarin must be reversed Further care is mainly directed at reducing secondary injury