AIH

Acute
Intracranial
Hemorrhage
INTRODUCTION
 INTRODUCTION

Intracerebral hemorrhage (ICH) is caused by bleeding within the

brain tissue itself — a life-threatening type of stroke. A stroke
occurs when the brain is deprived of oxygen and blood supply.
ICH is most commonly caused by hypertension, arteriovenous
malformations, or head trauma. Treatment focuses on stopping
the bleeding, removing the blood clot (hematoma), and relieving
the pressure on the brain
 PATHOPHYSIOLOGY
Blood from an intracerebral hemorrhage accumulates as a mass that can dissect through
and compress adjacent brain tissues, causing neuronal dysfunction. Large hematomas
increase intracranial pressure. Pressure from supratentorial hematomas and the
accompanying edema may cause transtentorial brain herniation, compressing the brain
stem and often causing secondary hemorrhages in the midbrain and pons.

If the hemorrhage ruptures into the ventricular system (intraventricular hemorrhage), blood
may cause acute hydrocephalus. Cerebellar hematomas can expand to block the 4th
ventricle, also causing acute hydrocephalus, or they can dissect into the brain stem.
Cerebellar hematomas that are > 3 cm in diameter may cause midline shift or herniation.

Herniation, midbrain or pontine hemorrhage, intraventricular hemorrhage, acute

hydrocephalus, or dissection into the brain stem can impair consciousness and cause
coma and death.
PATIENT DATABASE
 PATIENT DEMOGRAPHICS

NAME: CL

AGE: 60/F

Ward / Bed Number: 5/11

Case Number: 0006

 HISTORY OF PRESENT ILLNESS
CC: Increased BP; dizziness
Admitting diagnosis: Hypertensive urgency
3 hrs PTA: Patient was found in the CR seated in front of the
toilet.

Complained of :
• (+)18h history of dizziness
• (+) BOV
• (+) HA
• (+) N/V
• (+) generalized weakness
• (+) decreased sensorium
• (-) chest pain, seizure, fever
 PAST MEDICAL HISTORY

more than 20 years; with fair compliance on

Hypertension – maintenance medicines (Losartan,
Amlodipine)

recently diagnosed but with no maintenance

T2DM –
meds
 FAMILY HISTORY

(+) Hypertension

(+) CVD

(+) Diabetes Mellitus

 LIFESTYLE

• Ambulatory

• Independent on ADLs

• Non-alcoholic beverage drinker

• Denies illicit drug use

• No known allergies to food and drugs

 REVIEW OF SYSTEMS
Gen survey: NRRR, (-)
BP: 220/140
Drowsky, NICRD murmurs
Awake, coherent, Soft, nontender,
HR: 76
MRD (-) edema
RR: 22 AS, PPC GCS 15

T: 36.1 ECE, CBS

 PRESENT WORKING IMPRESSION

• Acute Intracranial Hemorrhage prob. Hypertensive

• Type 2 Diabetes Mellitus, uncontrolled

• Aspiration Pneumonia

• Hypertension St. II, uncontrolled

• Complicated Urinary Tract Infection

LABORATORY RESULTS
 DATE
VITAL
SHIFT INTERPRETATION
SIGNS
N 190/30 140/110 140/80 140/90 Elevated due to
Blood
D 190/30 150/110 140/80 140/90 uncontrolled
Pressure
E 190/30 140/110 160/80 140/90 Hypertension

N - - - -
Heart
Rate
D - - - -
E 92 92 80 -
N - - - -
Respirator
y Rate
D - - - -
E 32 20 20 -
 DATE
HEMA- NORMAL
INTERPRETATIONS
TOLOGY VALUES 9/12 -
RBC 4-6 x1012 /L 4.12 - - NORMAL
Hgb 120-180 g/L 128 - - NORMAL
HCT 0.37–0.54 % 0.37 - - NORMAL
MCV 80–100 fL 89.7 - - NORMAL
MCH 27–31 pg 30.8 - - NORMAL
MCHC 320–360 g/L 345 - - NORMAL
Due to systemic
WBC 4–11 x109 /L 21.8 - - INCREASED
bacterial infection
Due to systemic
NEUT 50-70% 86 - - INCREASED
bacterial infection
LYMPH % 20-44% 9 - - NORMAL
MONO % 2-9% 4 - - NORMAL
EOSIN % 0-45% 0 - - NORMAL
BASO % 0-2% 0 - - NORMAL
PLT 150-450 x109 /L 405 - - NORMAL
 DATE
PRO-
NORMAL
THROMBINE INTERPRETATIONS
VALUES 9/1 - -
TIME

Control 12-15 secs 12.5 - - NORMAL

Patients
- 11.8 - -
Value Vitamin K
Activity - 118.8 - - deficiency
INR (1.0) 0.94 - -
 DATE
ARTERIAL
BLOOD NORMAL
9/18 9/18 9/19 INTERPRETATIONS
GAS VALUES
(5AM) (8M) (5AM)
Due to
pH 7.35-7.45 7.424 7.492 7.530 INCREASED hyperventilation

PCO2 Due to Diabetic

34-45 mmHg 24.6 18.3 5.8 DECREASED
Ketoacidosis
Heart
PO2 90-100 mmHg0 79.4 53.2 71.0 DECREASED decompensation
Due to
HCO3 22-26 mmol/L 16.0 14.2 21.7 DECREASED Metabolic
Acidosis
BE 0-2 mEq/l -5.2 -6.6 1.0
%O2 STAT - 95.2% 89.3% 95.2%
 DATE
BLOOD NORMAL
INTERPRETATIONS
CHEMISTRY VALUES 9/16 9/18 9/20
BUN 2.8-6.4 mmol/L 5.5 8.5 5.9 NORMAL
Creatinine 53-115 µmol/L 70 66 53 NORMAL
Albumin 34-59 g/L 50 - - NORMAL
140.-148 Decreased due
Sodium 139 135 138 DECREASED
mmol/L to ICH/
Uncontrolled
Potassium 3.6-5.2 mmol/L 4.0 3.8 3.4 DECREASED
HTN Stage II
Calcium 2.2-2.62
(Ca2+) mmol/L 2.07 - 2.43 NORMAL
Ionized (Ca2+) 1.1—1.35
0.81-158
Phosphorus - 0.92 - NORMAL
mmol/L
0.74-1.0
Magnesium 0.67 - 0.71 NORMAL
mmol/L
0.110-0.430
Uric Acid 0.333 - -
mmol/L
 DATE
BLOOD NORMAL
INTERPRETATIONS
CHEMISTRY VALUES 9/16 9/18 9/20
ALT/ SGPT 30-65 µ/L 28 - - DECREASED
AST/SGOT 15-37 µ/L 25 - - NORMAL
Cholesterol 4.2-5.2 mmol/L 3.09 - - DECREASED
0.34-2.28
Triglycerides 1.52 - - NORMAL
mmol/L
LDH 100-190 µ/L 0.69 - -
LDL 1.00-3.8 µ/L 1.56 - - NORMAL
0.830-2.490
HDL 0.84 - - NORMAL
µ/L
 DATE
URINALYSIS INTERPRETATION
9/6
Color - Yellow - -
Trans- Slightly
- - -
parency hazy
Specific 1.016- Due to Diabetes
1.031 - - INCREASED
Gravity 1.022 Mellitus
pH 4.6-6.5 5.0 - -
Due to Diabetes
Sugar (-) +3 - - Positive Mellitus
RBC 0-2 /hpf 22/5 - -
WBC 0-5 /hpf 79/18 - -
 DATE
URINALYSIS INTERPRETATION
9/6
WBC 0-5 /hpf 79/18 - -
Epithelial
Few 13/3 - -
Cells
Bacteria (-) 75/17 - - Due to Complicated UTI
Mucous
Few 44/10 - - Due to Infection
Threads
(+) Due to uncontrolled
Ketones (-) +1 - -
Diabetes Mellitus
 DATE
OTHER NORMAL
INTERPRETATIONS
TEST VALUES

RBS 444 - -
140-180
CBG 279 434 - High Due to DM
mg/dL
HbA1C 13.2 - -
Trop I HS <15.6 496.2 301.96 -
 GRAM STAIN
DATE SPECIMEN PMNS ORGANISM AFS

Sputum >25/LPF Gram (+)

cocci in pairs : 0-1/OIF

Gram (-)
bacilli : 0-5/OIF
 ECG/RADIOGRAPHY
DATE: 9/8 : 6:23 AM
IMPRESSION:
• RSR
• NA
• LVH
• ICVD
 PLAIN CRANIAL CT
DATE:
IMPRESSION:
• Chronic infact
• Acute ICH,
middle cerebellar peduncle,
mild cerebellar atrophy
DRUG THERAPY PLAN
Drug Prescribed Indication

Ceftriaxone 2g IV OD Treatment of Complicated UTI

Clindamycin 600mg IV
Treatment for Aspiration Pneumonia
Q8
Azithromycin 500mg tab
Treatment for Aspiration Pneumonia
OD PO x 5 days
Insulin glargine 20 u SC Management of Type 2 Diabetes
OD Mellitus
Insulin HR 6-6-6 u SC Management of Type 2 Diabetes
TID Mellitus
Drug Prescribed Indication
Carvedilol 6.25mg tab Management of Hypertension Stage II
BID & Heart Failure
Telmisartan 80mg tab Management of Hypertension Stage II
OD & Heart Failure
Atorvastatin 80mg tab Management of Hypertension Stage II
OD & Heart Failure

Lactulose 30cc OD Management in prevention of Straining

Management of Dizziness &

Flunarizine 5mg tab OD
Headache
Drug Prescribed Indication
Omeprazole 440mg cap
Management of Stress-induced ulcer
OD

ISDN 10mg tab TID Management of Hypertension Stage II

Management of Dizziness &

Betahistine 8mg tab TID
Headache
Drug Prescribed Indication

PRN:

4 units HR SC For CBC ≥ 100 mg/dL

6 units HR SC For CBC ≥ 250 mg/Dl

DRUG THERAPY PROBLEM
 Problem & Intervention and
Management Action
Atorvastatin + Azithromycin
• Azithromycin may enhance the • Use extra caution when
myopathic (rhabdomyolysis) effect considering the use of
of Atorvastatin Azithromycin together with
Atorvastatin,
• Monitor patients more closely for
evidence of Atorvastatin toxicity
(muscle aches / pains, renal
dysfunction
 Problem & Intervention and
Management Action
Carvedilol + Azithromycin
• P-glycoproteins / ABC1 inhibitors • Monitor for increased effects of P-
may increase the serum glycoprotein (Pgp) substrates if a
concentration of P- Pgp inhibitor is started or if dose
glycoprotein/ABC1. of a concurrently used Pgp
• P-glycoprotein inhibitors may also inhibitor is increased.
enhance the distribution of P- • Monitor for decrease substrate
glycoprotein substrates to specific effects/toxicity if a Pgp inhibitor is
celss/tissues/organs where P- discontinued or if the dose of
glycoprotein is present in large concurrentlt used Pgp inhibitor is
amounts. decreased
 Problem & Intervention and
Management Action
Insulin Glargine + Carvedilol
• Beta-blockers may enhance the • Monitor for increased therapeutic
hypoglycemic effect of Insulins effects of Insulin if a beta-blocker
is initiated/dose increased or
decreased effects if a beta-
blocker is discontinued/dose
decreased
Clindamycin
• Drug has an incomplete • Respectfully suggesting to specify
medication order duration of treatment. (7-8 days)
 Problem & Intervention and
Management Action
ISDN + Carvedilol
• Carvedilol may enhance the • Monitor patients closely for
hypoglycemic effect of additive hypotensive effects if two
Hypotension-Associated Agents or more of these agents are
• Increased risk of hypotension combined
Ceftriaxone
• Drug has an incomplete • Respectfully suggesting to specify
medication order duration of treatment. (5-14 days)
 Problem & Intervention and
Management Action
Atorvastatin 80mg tab OD
• Study shows increase risk of • Respectfully suggesting to
dose-related rhabdomyolysis or consider lowering the dose of
myopathy. Atorvastatin 80 mg tab OD to 40
• Also, study shows that patient mg tab OD.
with recent stroke of TIA receiving
long-term therapy with high-dofr
(80 mg/day) atorvastatin may
increased risk of hemorrhagic
stroke
 Problem & Intervention and
Management Action
Azithromycin 500 mg tab OD PO for
5 days
• Azithromycin is judged to be • Respectfully suggesting to
inappropriate to patient with discontinue medication.
pneumonia in oral route.
• Also, may increased risk factor of
worsening of Pneumonia.
ISDN 10 mg/tab TID
• Indicated for treatment of HF only • Respectfully suggesting to
if ACE inhibitors, ARBs or discontinue medication.
Angiotensin II-neprilysin inhibitor
cannot be tolerated by patients.
 Problem & Intervention and
Management Action
Insulin Glargine & Insuline Regular
• Respectfully suggesting to shift to
Isophane (Isophane + Insulin
Regular combination)/ with
combination of short acting to
long acting insulin is fixed.
• Hypoglycemic effects is better
maintained with Insulin HR +
Isophane compared to Insulin HR
+ Insulin glargine.
 Problem & Intervention and
Management Action
Dose of Omeprazole is too high

• Respectfully suggesting to lower

the dose.

• Flunarizine can cause dizziness

• Respectfully suggesting to
discontinue the medication.
PHARMACIST CAREPLAN
 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To eradicate Compliance:
pathogen causing ‾ Clindamycin 600 mg IV ‾ Culture and
pneumonia and q8 for 7 days Sensitivity
provide
symptomatic relief ‾ Watch out for
Treatment of hypersensitivity,
metallic taste and
Aspiration abdominal pain
Pneumonia ‾ Respectfully
suggesting to
discontinue
Azithromycin 500 mg
tab OD for 5 days
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to discontinue
Azithromycin 500 mg tab OD PO for 5 days .

Discussion
Azithromycin is judged to be inappropriate in patients with
pneumonia via the oral route. Increased risk factor or
worsening of Pnuemonia may occur.

Reference/s: Medscape, Lexicomp

 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To eradicate Compliance: Labs
infection and ‾ Ceftriaxone 2g IV OD ‾ UA
prevent further at 8am for 7 days ‾ Culture and
complications Sensitivity
Treatment of ‾ Dysuria
Urinary
Tract Monitor S/S of:
‾ Anaphylaxis
Infection
 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To reduce risk of Compliance:
injury and prevent ‾ Telmisartan 80mg tab ‾ Blood Pressure
occurrence of OD
thromboembolic Closely monitor
events ‾ Blood Pressure
Management of ‾ Discontinue if
Blood Pressufre
Acute falls 120/80
Intracranial mmHg
Hemorrhage
Watch out for S.E.
‾ Diziness
 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To manage Fever ‾ Respectfully ‾ Body Temperature
and protect suggesting to initiate
neurologic function therapy with Watch our for S.E.
Paracetamol 500 mg ‾ Skin rash
Management of tab PO PRN if ‾ Hypersensitivity
Acute temperature is Reaction
>37±0.5oC
Intracranial To maintain Serum ‾ Respectfully Labs
Hemorrhage Osmloraity of 300- suggesting to initiate ‾ Serum osmolarity
320 mmol/kg PNSS IV 1000ml 25
drops/min
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to initiate therapy with
Paracetamol 500 tab PO PRN if temperature is >37±0.5oC.

Discussion
Sources of Hyperthermia (temperature >38oC) should be
identified and treated. Antipyretic medications should be
administered to lower temperature in hypernthermic
patients with ICH.
Reference/s: ASA Guidelines 2018
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to use PNSS as infusion.
Avoid dextrose containing IV Fluids.

Discussion
The patient has diabetes which can increase serum glucose
level; increased serum glucose level is contraindicated in ICH.
Maintain CBG of 140-180 mg/dL.

Reference/s: IM Platinum
 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To manage Diziness Compliance Watch our for S.E.
and provide relief of ‾ Betahistine 8 mg tab ‾ Skin rash
Headache TID ‾ Tachycardia
‾ Ortostatic and
Management of ‾ Respectfully Postural
suggesting patient to Hypotension
Acute avoid quickly standing
Intracranial up
Hemorrhage ‾ Respectfully
suggesting to
discontinue Flunarizine
5 mg tab OD
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to discontinue Flunarizine.

Discussion
Flunarizine causes dizziness, as part of its side effects. The
patient may gain weight, as part of its side effect, which is
contraindicated in patients with Heart Failure.

Reference/s: IM Platinum, Lexicomp

 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To prevent straining Compliance Labs
during defacation ‾ Lactulose 30cc OD ‾ Sodium
‾ Potassium

Management of Watch out for S/S of

‾ Hypernatremia
Acute ‾ Hypokalemia
Intracranial
Hemorrhage
 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To normalize Compliance
workload of heart ‾ Carvedilol 6.25 mg tab ‾ Blood Pressure
and reverse Cardiac BID ‾ Heart Rate
remodelling
Management of ‾ Respectfully
Heart suggesting to
discontinue ISDN 10
Failure mg tab TID

‾ Respectfully ‾ HDL
suggesting to reduce ‾ LDL
Atorvastatin 80 mg to ‾ Triglycerides
40 mg tab OD ‾ Total Cholesterol
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to discontinue ISDN 10
mg tab TID.

Discussion
ISDN is useful for heart failure patients with reduced ejection
fraction only in patients with intolerance to ACE inhibitors or
Angiotensin II Receptor blockers.

Reference/s: Lexicomp
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to reduce dose of
Atorvastatin 80 mg tab OD to 40 mg tab OD.

Discussion
Atorvastatin causes rhabdomyolysis. At higher dose, it leads to
more incidence of myalgia. Thus, it is beneficial for the patient
to reduce the dose since the patient is experiencing generalized
weakness.
Reference/s: Lexicomp
 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To maintain a CBG Compliance
of 14-180 mg/dL ‾ Respectfully ‾ CBG
and prevent further suggesting to shift
complications Insulin to Insulin HR + ‾ Monitor closely for
Insulin Isophane CBG <140-180
Management of mg/dL
‾ Morning: Give 2/3rd of
Diabetes daily Insulin SC
Mellitus II
‾ Evening: Give 1/3rd of
daily Insulin SC 15
minutes before meals
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to shift Isophane with
combination of short-acting to long-acting insulin.

Discussion
Hypoglycemic effect is better maintained with Insulin HR +
Isophane, compared to Insulin HR + Glargine.

Reference/s: Medscape
 HEALTH PHARMACO-
RECOMMENDATION MONITORING
CARE NEED THERAPEUTIC
AND INTERVENTION PARAMETERS
GOAL
To maintain PaCO2 ‾ Correct underlying ‾ PaCo2
of 30-35 mmHg and diseases of patient ‾ O2 saturation
Management of
O2 saturation of ‾ Hyperventilation for O2
Respiratory NLT 94% saturation <94%
Alkalosis

To prevent stress- ‾ Respectfully Watch out for S.E.

Management of induced ulcer suggesting to decrease ‾ Headache
dose of Omeprazole ‾ Skin rash
Stress- 440 mg cap OD to ‾ Abdominal pain
induced Omeprazole 40 mg cap
OD
ulcer
 PHARMACIST’S NOTES
To: Doctor/Nurse
Re: Patient
Recommendation: Respectfully suggesting to decrease dose of
Omeprazole 440 mg cap OD to Omeprazole 40 mg cap OD.

Discussion
Dose is too high, recommended dose for stress-induced ulcer
prophylaxis in critically ill patients is Omeprazole 40 mg cap
OD.

Reference/s: Medscape, Lexicomp

 THANK YOU

AGUILOR ꟷ AGUSTIN ꟷ ALVIAR ꟷ ASUNCION