Brain Hemorrhage Management

Initial Management

The American Heart Association recommends providing ventilatory and cardiovascular support while transporting the patient to the closest facility prepared to care for acute stroke patients 1
Obtain focused history regarding symptom onset timing and medical history, including medications and drug use, as recommended by the American Heart Association 1
The American College of Emergency Physicians suggests performing urgent neurological evaluation including pupillary assessment and Glasgow Coma Scale (GCS) motor score 2
Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during initial interventions, as recommended by the World Journal of Emergency Surgery 3

The American College of Critical Care Medicine recommends securing airway via tracheal intubation for patients with GCS score of 8 or less 4
Maintain arterial partial pressure of oxygen (PaO₂) between 60-100 mmHg, as suggested by the American Thoracic Society 2
The American Heart Association recommends maintaining arterial partial pressure of carbon dioxide (PaCO₂) between 35-40 mmHg to prevent cerebral vasoconstriction and risk of brain ischemia 2
Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery, as recommended by the World Journal of Emergency Surgery 3

The American Association of Neurological Surgeons recommends urgent neurosurgical consultation and intervention for all salvageable patients with life-threatening brain lesions 2
Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction should undergo surgical evacuation, as recommended by the American Heart Association 6

The American College of Chest Physicians recommends implementing mechanical thromboprophylaxis with intermittent pneumatic compression and/or anti-embolic stockings as soon as possible 5
Employ pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled, as suggested by the American College of Chest Physicians 5
Maintain normothermia through early application of measures to reduce heat loss and warm hypothermic patients, as recommended by the American College of Critical Care Medicine 5

The American Heart Association recognizes that most patients who die from ICH do so during initial hospitalization, often in the setting of withdrawal of support due to presumed poor prognosis 6
Avoid early pessimistic prognostication that may lead to self-fulfilling prophecies of poor outcome by limiting aggressive care in severely ill ICH patients who still have possibilities of favorable outcome, as recommended by the American Heart Association 6

The American College of Emergency Physicians recommends not delaying intubation in patients with low GCS scores, as this is a clear indication for airway protection 4
Avoid hypotension and hypoxia, which can worsen secondary brain injury, as recommended by the American Heart Association 4
The American Heart Association suggests not relying solely on clinical characteristics to determine whether symptoms are due to ischemia or hemorrhage, as neuroimaging is mandatory 1