1. Continuous Neurological Monitoring

Frequent assessment of consciousness and brainstem function is essential to detect early deterioration.

Glasgow Coma Scale (GCS)

• Frequency: Hourly to bi-hourly during the first 72 hours; can extend to every 4 hours once stable.
• Components:
  • Eye Opening (E): 1–4 points
  • Verbal Response (V): 1–5 points
  • Motor Response (M): 1–6 points
  • Total Score: 3–15
• Trending: Document each component and graph changes to catch subtle declines.

Pupillary Checks

• Assess size (in mm), symmetry, and light reactivity at the same intervals as GCS.
• Anisocoria (>1 mm difference) or sluggish reaction may herald herniation.

2. Intracranial Pressure Monitoring

In patients at high risk for elevated ICP, monitoring guides therapy and prognostication.

Indications

• GCS ≤ 8 with CT evidence of large hematoma or intraventricular extension.
• Clinical signs of raised ICP: headache, vomiting, bradycardia with hypertension (Cushing’s triad).

Modalities

• External ventricular drain (EVD): Measures ICP and allows CSF drainage; risk of infection.
• Intraparenchymal probe: Continuous pressure recording; no drainage capability.

Interpretation & Thresholds

3. Prevention of Secondary Brain Injury

Maintain optimal physiologic parameters to protect perihematomal tissue.

• Oxygenation: Target PaO₂ > 80 mmHg via supplemental O₂ or mechanical ventilation. Avoid hypoxia.
• Ventilation: Maintain PaCO₂ 35–45 mmHg. Reserve brief hyperventilation (PaCO₂ ~ 30 mmHg for ≤ 1–2 hrs) for acute ICP crises only, as a bridge to more definitive therapy.
• Glycemic Control: Aim for blood glucose levels of 140–180 mg/dL (7.8–10.0 mmol/L) with insulin infusion if necessary. Avoid hypoglycemia (< 70 mg/dL or < 3.9 mmol/L).
• Temperature Management: Maintain normothermia (36.0–37.5 °C) with antipyretics and surface or endovascular cooling devices if fever occurs. Prophylactic hypothermia is not recommended.

4. Complication Surveillance and Management

Early prevention and treatment of systemic and neurologic complications are critical.

• Seizures
  • Prophylaxis: Not routinely recommended in seizure-free patients. Continuous EEG monitoring may be considered in patients with fluctuating mental status.
  • Treatment: Levetiracetam 500–1500 mg IV/PO q12h is a common first-line agent; adjust dose for renal function. Treat clinical seizures promptly.
• Venous Thromboembolism (VTE)
  • Initiate intermittent pneumatic compression (IPC) devices on day 1 for all immobile patients.
  • Consider low-dose unfractionated heparin or low-molecular-weight heparin (LMWH) for VTE prophylaxis at 24–48 hours after ICH onset if a repeat CT scan confirms hematoma stability.
• Infection Prevention
  • Implement VAP (Ventilator-Associated Pneumonia) and CAUTI (Catheter-Associated Urinary Tract Infection) bundles: head-of-bed elevation (30-45 degrees for VAP), oral care with chlorhexidine, daily review of necessity for invasive lines and catheters.
  • Minimize duration of invasive lines and catheters.
• Electrolyte Management
  • Sodium: Target normonatremia (typically 135–145 mEq/L). Correct hyponatremia based on etiology (e.g., SIADH vs. cerebral salt wasting). Avoid rapid correction.
  • Maintain potassium > 4.0 mEq/L and magnesium > 2.0 mg/dL to reduce arrhythmia and potential seizure risk.

5. Sedation Interruptions and Daily Neurological Evaluations

Balancing adequate sedation with the need for accurate neurologic exams and delirium prevention.

Sedation Vacations (Daily Interruption of Sedation)

• Safety criteria: Stable hemodynamics, controlled ICP (if monitored), no active seizures, no escalating sedative requirements for agitation.
• Monitoring during interruption: Assess for agitation, pain, ventilator asynchrony, and ICP spikes. Resume sedation at a lower dose if tolerated, or previous dose if needed.

Delirium Screening and Management

• Use a validated screening tool like the Confusion Assessment Method for the ICU (CAM-ICU) at least once daily in at-risk patients.
• Employ nonpharmacologic strategies first: optimize sleep hygiene, frequent reorientation, early mobilization, address sensory impairments (hearing aids, glasses). Minimize use of benzodiazepines.

6. Early Rehabilitation and Multidisciplinary Coordination

Early, coordinated rehabilitation drives better functional outcomes.

Mobilization Criteria

• Hemodynamically stable without escalating vasopressor support.
• Controlled ICP (if monitored) and no new or worsening neurologic deficits.
• Secure airway (if intubated) and stable respiratory status.

Therapy Integration

• Physical Therapy (PT): Early activities include bed mobility, passive/active range-of-motion exercises, progressing to sitting, standing, and ambulation as tolerated.
• Occupational Therapy (OT): Focus on activities of daily living (ADLs), cognitive assessments, and recommendations for adaptive equipment.
• Speech Therapy (ST): Perform swallowing assessment (dysphagia screening) before oral intake, and provide communication support for aphasia or dysarthria.

7. ICU De-escalation and Transition Planning

Structured criteria and communication tools ensure safe transfer to lower acuity settings.

Step-down Criteria (from ICU to a lower level of care)

• Stable GCS for ≥ 24 hours.
• No active ICP monitoring or need for acute ICP management.
• Ventilator weaning initiated or successfully extubated; stable respiratory status on minimal support.
• No anticipated acute neurosurgical interventions.
• Absence of other unstable medical conditions requiring ICU-level care.

Handoff Process

• Utilize a standardized communication tool such as SBAR (Situation, Background, Assessment, Recommendation).
• Clearly document current neurological status, goals of care, pending studies, medication reconciliation, and specific follow-up plans.

8. Patient and Family Education and Support

Engaging patients (where possible) and caregivers in prognosis discussions and care planning enhances shared decision-making and aligns care with patient values.

Prognosis Communication

• Use validated prognostic tools (e.g., ICH Score) in conjunction with clinical context; provide information in an understandable manner, balancing realism with hope.
• Allow ample time for questions and emotional processing; revisit prognosis discussions as the patient’s clinical status evolves.

Goals of Care & Advance Directives

• Explore patient values and previously expressed wishes regarding life-sustaining treatments. Document preferences early, but avoid making premature decisions on Do-Not-Attempt-Resuscitation (DNAR) orders within the first 24-48 hours unless clearly aligned with pre-existing patient wishes or futility.
• Reassess goals of care decisions regularly, especially after the initial 48–72 hours when the clinical trajectory often becomes clearer.

Support Resources

• Involve social work, palliative care specialists, and rehabilitation coordinators early to provide psychosocial support and assist with discharge planning.
• Provide information on community support groups, financial assistance programs, and home care services as appropriate.