BP Control in IVH with Herniation

[HLxDrummer]

Hey guys,

ED resident here and wanted you to drop some knowledge on me. Recently had patient with IVH who was herniating. BP 220s systolic. Initially planned to do a Cardene drip for SBP goal 140-160 but the attending brought up the point of needing the BP to perfuse since the ICP was elevated.

How do you guys handle this situation?

I can see the higher pressure making the bleed worse, but also can see their point of dropping CPP but dropping the MAP.

Obviously can't fix this in the ED but curious what you guys would have done.

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[deleted547339]

Hey guys,

ED resident here and wanted you to drop some knowledge on me. Recently had patient with IVH who was herniating. BP 220s systolic. Initially planned to do a Cardene drip for SBP goal 140-160 but the attending brought up the point of needing the BP to perfuse since the ICP was elevated.

How do you guys handle this situation?

I can see the higher pressure making the bleed worse, but also can see their point of dropping CPP but dropping the MAP.

Obviously can't fix this in the ED but curious what you guys would have done.

Forest, meet trees.

 

[Groove]

Hey guys,

ED resident here and wanted you to drop some knowledge on me. Recently had patient with IVH who was herniating. BP 220s systolic. Initially planned to do a Cardene drip for SBP goal 140-160 but the attending brought up the point of needing the BP to perfuse since the ICP was elevated.

How do you guys handle this situation?

I can see the higher pressure making the bleed worse, but also can see their point of dropping CPP but dropping the MAP.

Obviously can't fix this in the ED but curious what you guys would have done.

Emergency Department Management of Hypertension in Acute Subarachnoid and Intracerebral Hemorrhage

https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.117.020058

 

[jdh71]

Hey guys,

ED resident here and wanted you to drop some knowledge on me. Recently had patient with IVH who was herniating. BP 220s systolic. Initially planned to do a Cardene drip for SBP goal 140-160 but the attending brought up the point of needing the BP to perfuse since the ICP was elevated.

How do you guys handle this situation?

I can see the higher pressure making the bleed worse, but also can see their point of dropping CPP but dropping the MAP.

Obviously can't fix this in the ED but curious what you guys would have done.

You’ll need the lower BPs because of the bleed in general. But I much more kindly agree with the above. That patient’s problem isn’t swelling in the brain per se nor is it CPP but all the blood in the skull pushing on the brain causing the herniation. That patient needs a crani or a very very frank discussion with family.

 

[SurfingDoctor]

Neurosurgical consult and hypertonic saline...

 

[TUGM]

Definitely needs a surgical consult, reversal if any anticoagulation on board, and/or discussion with family about goals of care in this scenario.

Specifically answering your questions, the general practice in neurocritical care is to lower the BP. How low is institutional. At our large, academic institution, we lower the BP goal to a MAP < 110. The data for the benefit of lowering BP acutely is not great. There is really no difference in outcomes w/ SBP < 140 as compared to SBP < 180. Some believe that SBP < 160 is a reasonable target.

Physiologically, we believe that acute BP control does help with bleed expansion, but in the case of herniation, more aggressive therapy is definitely needed to save someone's life. As mentioned above, CPP is important to consider, but the herniation from mass effect will kill the patient more immediately.

Disclaimer: am neurocritical care fellow.

 

[Hamhock]

Agree with above regarding BP (I would probably shoot for 140-160 in this patient but not freak out if up to 180) and the need for decompression (early EVD and crani).

Do not risk hypotension.

However, there are interventions in the ED to help ICP also. As mentioned above, there's 3% or 23%. Also, deep sedation, NMB (nimbex infusion until you know more), maybe some early (not prolonged) mild hyperventilation, positioning, temperature management, etc...

HH

 

[HLxDrummer]

Thanks for all the input, guys!

Ya, definitely poor prognosis. Didn't help that neurosurgery didn't answer their pages for two hours.

We did do a 3% bolus up front, HOB elevated. Considered mannitol but attending didn't think it would make a difference in the end.

Didn't do sedation I guess cause he was a GCS 3, didn't seem like it was needed. Plus figured it would help for surgery's exam. Would you guys sedate this patient? I guess fent/prop come off fairly quickly.

 

[jdh71]

Thanks for all the input, guys!

Ya, definitely poor prognosis. Didn't help that neurosurgery didn't answer their pages for two hours.

We did do a 3% bolus up front, HOB elevated. Considered mannitol but attending didn't think it would make a difference in the end.

Didn't do sedation I guess cause he was a GCS 3, didn't seem like it was needed. Plus figured it would help for surgery's exam. Would you guys sedate this patient? I guess fent/prop come off fairly quickly.

Basically none of most of the above interventions except for that which will arguably decrease the bleeding in the head (BP control) will actually help though. It’s not “brain swelling” that is your problem right? Trying to make the brain smaller because of all of the blood in the head is something you can try but . . . It’s completely unacceptable that you can’t get a neurosurgeon to return a page for two hours.

 

[jdh71]

discussion with family about goals of care in this scenario.

This is basically the first, second, third thing you should definitely do in the head bleed with already herniation scenario.

“Your father is dying quickly if not already dead from this and could become brain dead any moment. IF a surgeon offers a craniectomy your father will highly likely never be like he was before this bleed and chance for severe severe brain damage is high. Would he want to live like that? I need you to make decisions for him because he can’t”

 

[chocomorsel]

So.. did it end well?

 

[deleted547339]

So.. did it end well?

Lolz.

 

[deleted547339]

Definitely needs a surgical consult, reversal if any anticoagulation on board, and/or discussion with family about goals of care in this scenario.

Specifically answering your questions, the general practice in neurocritical care is to lower the BP. How low is institutional. At our large, academic institution, we lower the BP goal to a MAP < 110. The data for the benefit of lowering BP acutely is not great. There is really no difference in outcomes w/ SBP < 140 as compared to SBP < 180. Some believe that SBP < 160 is a reasonable target.

Physiologically, we believe that acute BP control does help with bleed expansion, but in the case of herniation, more aggressive therapy is definitely needed to save someone's life. As mentioned above, CPP is important to consider, but the herniation from mass effect will kill the patient more immediately.

Disclaimer: am neurocritical care fellow.

I’m sorry.

 

[TUGM]

I’m sorry.

I’m not. It is a great field. Plus I will be an neuroendovascular fellow as well, so I will have the joy of admitting people to the ICU and asking for strict MAP goals of 100-105.

 

[HLxDrummer]

So.. did it end well?

Got up to the ICU... they put in on IO, gave 23%. Shortly after became suddenly hypotensive. While they were starting Levo the patient coded. Family decided on DNR and when the "provider" got back to the patient, they had ROSC. Went comfort measures/palliation.

 

[dpmd]

Lolz.

Perhaps they mean "well" as in anything that doesn't leave the patient trached and pegged in a LTAC fr the rest of their miserable excuse for a life. So kinda yes.

 

[Merely]

Got up to the ICU... they put in on IO, gave 23%. Shortly after became suddenly hypotensive. While they were starting Levo the patient coded. Family decided on DNR and when the "provider" got back to the patient, they had ROSC. Went comfort measures/palliation.

What does provider in quotes mean

 

[deleted547339]

Perhaps they mean "well" as in anything that doesn't leave the patient trached and pegged in a LTAC fr the rest of their miserable excuse for a life. So kinda yes.

Which is why I hate neuro-icu.

 

[jdh71]

Which is why I hate neuro-icu.

I don't hate it. I find neuro-cc fascinating. I end up doing A LOT of it. But . . . I think our ability to "save" people (keep them alive) has gone way past our culture's expectations of what that means. Lay people can't obviously understand the devastating end points. We are all not very good yet (but getting better) at talking to people and setting expectations. We really need to find a way to say, "No," but may never get there with our current medicolegal situation. And then the ethics - we can "save," but . . . should we? For most of us in the trenches it's very obvious. Some of the very religious christian/muslim/jewish drive the flog, especially once we start down the road of "saving". I had one Iraqi immigrant tell me, "You do not understand, we CANNOT tell you to stop," with a very pained look on his face, "In Iraq the doctors would have just told us there is nothing to do and would have let him die, now . . . it is in Allah's hands, and God will need to stop his heart." The gentleman thankfully reached brain death, even though the heart was beating, and this allowed us to stop the aggressive measures. The family was still unsatisfied with this on some level, but also seemed glad our laws took over for them.

Until we find someway for serious neuroregeneration, I am not convinced we should be doing crani's for swelling or bleeding in basically anyone. I mean we all know or have a heard a story where someone (usually younger) is like "fine" now after having a crani for some disaster in their head, but that is such a low probability gamble in almost all cases, is it worth absorbing the disastrous cases as a society for the sake of the few "miracles". I have ambivalence, but the longer I practice, even though it's only been five years, I am siding more and more in the camp of "we need to not".

 

[Robotic Wis-Hipple]

I don't hate it. I find neuro-cc fascinating. I end up doing A LOT of it. But . . . I think our ability to "save" people (keep them alive) has gone way past our culture's expectations of what that means. Lay people can't obviously understand the devastating end points. We are all not very good yet (but getting better) at talking to people and setting expectations. We really need to find a way to say, "No," but may never get there with our current medicolegal situation. And then the ethics - we can "save," but . . . should we? For most of us in the trenches it's very obvious. Some of the very religious christian/muslim/jewish drive the flog, especially once we start down the road of "saving". I had one Iraqi immigrant tell me, "You do not understand, we CANNOT tell you to stop," with a very pained look on his face, "In Iraq the doctors would have just told us there is nothing to do and would have let him die, now . . . it is in Allah's hands, and God will need to stop his heart." The gentleman thankfully reached brain death, even though the heart was beating, and this allowed us to stop the aggressive measures. The family was still unsatisfied with this on some level, but also seemed glad our laws took over for them.

Until we find someway for serious neuroregeneration, I am not convinced we should be doing crani's for swelling or bleeding in basically anyone. I mean we all know or have a heard a story where someone (usually younger) is like "fine" now after having a crani for some disaster in their head, but that is such a low probability gamble in almost all cases, is it worth absorbing the disastrous cases as a society for the sake of the few "miracles". I have ambivalence, but the longer I practice, even though it's only been five years, I am siding more and more in the camp of "we need to not".

Bundled billing will induce a lot of movement in that regard imo. We do lots of cardiac, oncologic, neurologic, etc surgery in pts with next to zero chance of meaningful recovery/survival. And I’m sure you guys see a ton of these types that never reach the OR yet still receive a lot of low yield care.

It feels cynical to say, but it’s true.

 

[alpinism]

Hey guys,

ED resident here and wanted you to drop some knowledge on me. Recently had patient with IVH who was herniating. BP 220s systolic. Initially planned to do a Cardene drip for SBP goal 140-160 but the attending brought up the point of needing the BP to perfuse since the ICP was elevated.

How do you guys handle this situation?

I can see the higher pressure making the bleed worse, but also can see their point of dropping CPP but dropping the MAP.

Obviously can't fix this in the ED but curious what you guys would have done.

The patient needs immediate craniotomy and EVD placement.

But if you must do something elevate HOB, hypertonic, and nicardipine to goal of SBP 160 is our protocol.

On another note I fully believe the above procedures should be within the realm of ED physicians given the above scenario and for cases that occur at rural hospitals without neurosurgery. Its ridiculous to wait 2+ hours if the patient is truly herniating.

 

[alpinism]

I don't hate it. I find neuro-cc fascinating. I end up doing A LOT of it. But . . . I think our ability to "save" people (keep them alive) has gone way past our culture's expectations of what that means. Lay people can't obviously understand the devastating end points. We are all not very good yet (but getting better) at talking to people and setting expectations. We really need to find a way to say, "No," but may never get there with our current medicolegal situation. And then the ethics - we can "save," but . . . should we? For most of us in the trenches it's very obvious. Some of the very religious christian/muslim/jewish drive the flog, especially once we start down the road of "saving". I had one Iraqi immigrant tell me, "You do not understand, we CANNOT tell you to stop," with a very pained look on his face, "In Iraq the doctors would have just told us there is nothing to do and would have let him die, now . . . it is in Allah's hands, and God will need to stop his heart." The gentleman thankfully reached brain death, even though the heart was beating, and this allowed us to stop the aggressive measures. The family was still unsatisfied with this on some level, but also seemed glad our laws took over for them.

Until we find someway for serious neuroregeneration, I am not convinced we should be doing crani's for swelling or bleeding in basically anyone. I mean we all know or have a heard a story where someone (usually younger) is like "fine" now after having a crani for some disaster in their head, but that is such a low probability gamble in almost all cases, is it worth absorbing the disastrous cases as a society for the sake of the few "miracles". I have ambivalence, but the longer I practice, even though it's only been five years, I am siding more and more in the camp of "we need to not".

The prognosis highly depends on the type and duration of bleeding. Extra axial hematomas are well documented to have good outcomes with rapid drainage. Several studies have shown epidural/subdural neurointact survival to be 67% and 32% respectively with <2 hr burr holes.

The problem with the United States and other first world countries is that we see mostly intra axial hematomas from lifestyle diseases in elderly unhealthy patients. In contrast third world countries see mostly extra axial hematomas from traumatic injuries that occur in young healthy patients. The hospital where I work in Haiti sees about 50 per year with neurointact survival of 70% last time I checked. I've personally done 4 burr holes with 2 of those surviving without any significant neuro deficits. My last one was a 7 year old boy in a motorcycle accident who walked out of the hospital and was back in school after 2 weeks.

 

[jdh71]

The prognosis highly depends on the type and duration of bleeding. Extra axial hematomas are well documented to have good outcomes with rapid drainage. Several studies have shown epidural/subdural neurointact survival to be 67% and 32% respectively with <2 hr burr holes.

The problem with the United States and other first world countries is that we see mostly intra axial hematomas from lifestyle diseases in elderly unhealthy patients. In contrast third world countries see mostly extra axial hematomas from traumatic injuries that occur in young healthy patients. The hospital where I work in Haiti sees about 50 per year with neurointact survival of 70% last time I checked. I've personally done 4 burr holes with 2 of those surviving without any significant neuro deficits. My last one was a 7 year old boy in a motorcycle accident who walked out of the hospital and was back in school after 2 weeks.

There are exceptions and anecdotes.

Glad your burr holes have saved some folks in Haiti.

 

[dpmd]

The prognosis highly depends on the type and duration of bleeding. Extra axial hematomas are well documented to have good outcomes with rapid drainage. Several studies have shown epidural/subdural neurointact survival to be 67% and 32% respectively with <2 hr burr holes.

The problem with the United States and other first world countries is that we see mostly intra axial hematomas from lifestyle diseases in elderly unhealthy patients. In contrast third world countries see mostly extra axial hematomas from traumatic injuries that occur in young healthy patients. The hospital where I work in Haiti sees about 50 per year with neurointact survival of 70% last time I checked. I've personally done 4 burr holes with 2 of those surviving without any significant neuro deficits. My last one was a 7 year old boy in a motorcycle accident who walked out of the hospital and was back in school after 2 weeks.

You live in Haiti or do you just go work there at times?

 

[alpinism]

You live in Haiti or do you just go work there at times?

Been going down there for a month the past few years.

 

[TooMuchResearch]

I don't hate it. I find neuro-cc fascinating. I end up doing A LOT of it. But . . . I think our ability to "save" people (keep them alive) has gone way past our culture's expectations of what that means. Lay people can't obviously understand the devastating end points. We are all not very good yet (but getting better) at talking to people and setting expectations. We really need to find a way to say, "No," but may never get there with our current medicolegal situation. And then the ethics - we can "save," but . . . should we? For most of us in the trenches it's very obvious. Some of the very religious christian/muslim/jewish drive the flog, especially once we start down the road of "saving". I had one Iraqi immigrant tell me, "You do not understand, we CANNOT tell you to stop," with a very pained look on his face, "In Iraq the doctors would have just told us there is nothing to do and would have let him die, now . . . it is in Allah's hands, and God will need to stop his heart." The gentleman thankfully reached brain death, even though the heart was beating, and this allowed us to stop the aggressive measures. The family was still unsatisfied with this on some level, but also seemed glad our laws took over for them.

Until we find someway for serious neuroregeneration, I am not convinced we should be doing crani's for swelling or bleeding in basically anyone. I mean we all know or have a heard a story where someone (usually younger) is like "fine" now after having a crani for some disaster in their head, but that is such a low probability gamble in almost all cases, is it worth absorbing the disastrous cases as a society for the sake of the few "miracles". I have ambivalence, but the longer I practice, even though it's only been five years, I am siding more and more in the camp of "we need to not".

I had two complete brain disasters in residency (EM with a lot of surgical/Neuro ICU) have what I would consider a good outcome. Both under 25, neither should have lived.

 

[jdh71]

I had two complete brain disasters in residency (EM with a lot of surgical/Neuro ICU) have what I would consider a good outcome. Both under 25, neither should have lived.

Are they working now? Feeding themselves and wiping their own asses?