Clinical review: Critical care management of spontaneous intracerebral hemorrhage

Table 4 Emergency management of the coagulopathic intracerebral hemorrhage patient

Scenario	Agent	Dose	Comments	Level of Evidence*
Warfarin	Fresh frozen plasma	15 ml/kg	Usually 4 to 6 units (200 ml) each are given	B
	or
	Prothrombin complex concentrate	15 to 30 U/kg	Works faster than fresh frozen plasma, but carries risk of disseminated intravascular coagulation	B
	and
	Intravenous vitamin K	10 mg	Can take up to 24 hours to normalize international normalized ratio	B
Warfarin and emergency neurosurgical intervention	Above plus rFVIIa	20 to 80 μg/kg	Contraindicated in acute thromboembolic disease	C
Unfractionated or low molecular weight heparin^†	Protamine sulfate	1 mg per 100 units of heparin, or 1 mg of enoxaparin	Can cause flushing, bradycardia, or hypotension, anticoagulation	C
Platelet dysfunction or thrombocytopenia	Platelet transfusion	6 units	Range 4 to 8 units based on size; transfuse to >100,000	C
	and/or
	Desmopressin (DDAVP)	0.3 μg/kg	Single dose required	C

*See Table 1 for descriptions of Levels of Evidence. ^†Protamine has minimal efficacy against danaparoid or fondaparinux. Reproduced with permission from Mayer SA, Rincon F: Management of intracerebral hemorrhage. Lancet Neurol 2005, 4: 662–672. rFVIIa, recombinant factor VII.

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