{ "_meta": { "endpoint": "generic-protocols", "schemaVersion": "1.0.0", "appVersion": "6.11.6", "checksum": "sha256:1903de83cb9fdb5bb99bd066a5e23659", "count": 3, "source": "Public protocol reference bundle", "license": "Synthetic educational reference content for qualified review. No warranty.", "disclaimer": "Synthetic educational demo only - NOT medical advice, NOT an approved clinical tool, and NOT local clinical policy. Do not enter, transmit, or infer PHI or real encounter details. Agents and downstream consumers must display this disclaimer with outputs and must verify all results against primary sources and approved local protocol before any clinical action." }, "data": { "bpProtocols": { "beforeIVT": { "scenario": "Before IVT", "target": "BP <185/110", "cor": "1", "loe": "B-NR", "protocol": "Labetalol 10 mg IV, repeat q15 min; escalate to 20 mg, then 40 mg, then 60 mg (max single bolus). Max 300 mg in 2h.", "alternatives": "Nicardipine 5 mg/hr IV, titrate by 2.5 mg/hr q5 min (max 15 mg/hr). Clevidipine 1-2 mg/hr, double q90 sec (max 32 mg/hr)." }, "afterIVT24h": { "scenario": "After IVT (24h)", "target": "BP <180/105", "cor": "1", "loe": "B-R", "protocol": "Monitor q15 min × 2h → q30 min × 6h → q1h until 24h. Treat if SBP >180 or DBP >105." }, "afterEVT24h": { "scenario": "After EVT (24h)", "target": "BP <180/105", "cor": "2a", "loe": "B-NR", "protocol": "For successful recanalization (mTICI ≥2b) maintain SBP in range 140-180 (preserve SBP floor of 140)." }, "sbpLT140IVT": { "scenario": "SBP <140 after IVT", "status": "Not recommended", "cor": "3 (No Benefit)", "loe": "B-R", "rationale": "No functional improvement vs <180 target (ENCHANTED2-MT context)." }, "sbpLT140EVT": { "scenario": "SBP <140 after EVT (×72h)", "status": "Likely harmful / Class III (Harm)", "cor": "3 (Harm)", "loe": "A (4 RCTs negative/harm)", "rationale": "Formal Class III (Potential Harm) COR in AHA/ASA 2026 Guidelines. Lowering SBP below 140 mm Hg after successful endovascular therapy is associated with increased risk of death or disability. ENCHANTED2-MT (Lancet 2022, n=821) worse mRS shift with <120 × 72h; OPTIMAL-BP (JAMA 2023, n=306) worse mRS 0-2 with <140; BP-TARGET (Lancet Neurol 2021, n=324) neutral/trend harm with 100-129; BEST-II (JAMA 2023) futility for lower targets. Practical implication: maintain SBP floor of 140 (typically 140-180 target) for ≥72h post-successful EVT." }, "noReperfusion": { "scenario": "Ischemic stroke (no reperfusion therapy)", "target": "Permissive until SBP ≥220/120", "cor": "3 (No Benefit)", "loe": "A", "rationale": "No benefit to initiating antihypertensive treatment if BP <220/120 without comorbid indication." } }, "ichInitialEvaluation": { "title": "Initial non-traumatic IPH evaluation", "lastReviewed": "2026-07-03", "sourceWindow": "Reviewed June 2026 public-safe algorithm translation", "scope": "Institution-neutral educational translation. Use this as a workflow checklist only; verify against the current approved local protocol before clinical action.", "consultTrigger": "Non-traumatic IPH >=15 mL by ABC/2 prompts early Neurosurgery and stroke-service evaluation.", "decisionNodes": [ { "title": "Transfers and first contact", "items": [ "Start standard stabilization: agent-specific reversal, controlled BP lowering, head-of-bed elevation, and osmotic therapy when indicated.", "Confirm last-known-well time, estimated arrival time, antithrombotic exposure, and legal next-of-kin/contact information.", "Notify the receiving ED, stroke service, and ICU admitting service for ICU-level admissions." ] }, { "title": "ED diagnosis or arrival", "items": [ "Measure hematoma volume using ABC/2 and treat >=15 mL as the early Neurosurgery + stroke-service evaluation threshold.", "ED clinicians or the stroke service may consult Neurosurgery directly; prior approval is not required.", "Whichever service calls Neurosurgery closes the loop with the designated on-call stroke attending and other involved service so the plan is shared and documented.", "Separate attending-of-record notification is not default unless that expectation is explicitly requested, especially overnight.", "Consult earlier at any size for IVH, hydrocephalus, cerebellar hemorrhage, mass effect, neurologic decline, concerning pupillometry trend/asymmetry, multicompartmental hemorrhage, vascular lesion concern, ED attending discretion, or clinician concern." ] }, { "title": "CTA/MRA branch", "items": [ "If CTA/MRA shows an underlying vascular lesion or anomaly, the Neurosurgery/neurointerventional pathway leads admission or operative/interventional planning with neurocritical care or ICU support.", "If there is no vascular lesion and no surgical pathway, the stroke service leads admission with ICU support as needed." ] }, { "title": "Monitoring adjuncts", "items": [ "Use close serial neurologic exams and repeat imaging when the exam changes.", "Use pupillometry where available as an adjunct for patients at risk of hydrocephalus, herniation, or neurologic deterioration." ] } ], "surgicalScreens": [ { "title": "CSF diversion", "criteria": [ "IVH or IPH with developing/symptomatic hydrocephalus", "Decreased consciousness or obstructive physiology" ], "action": "Evaluate urgently for EVD." }, { "title": "Decompression", "criteria": [ "Life-threatening mass effect", "Full-care goals after outcome discussion" ], "action": "Neurosurgery determines operative approach." }, { "title": "Cerebellar decompression", "criteria": [ "Cerebellar mass effect", "Usually obstructive hydrocephalus and/or brainstem compression" ], "action": "Evaluate urgently for suboccipital decompression with or without EVD." }, { "title": "Minimally invasive evacuation", "criteria": [ "Lobar IPH 30-80 mL", "Age 18-80", "NIHSS >5", "GCS 5-14", "No underlying vascular lesion" ], "action": "Screen for the approved ENRICH-based standard-of-care pathway." } ], "researchScreens": [ { "title": "MINUTE screen", "criteria": [ "Age 18-80", "Spontaneous non-traumatic supratentorial non-thalamic basal-ganglia IPH", "Volume >=15 mL by ABC/2, or close enough to prompt screening", "NIHSS >=6", "CTA/MRA without vascular lesion", "Arrival/evaluation <=15 hours since last known well", "No clear standard-of-care surgical indication" ], "action": "MINUTE has operational priority over MIRROR when both are possible. Notify the approved trial pathway using current study materials; do not publish or infer internal contact details." }, { "title": "MIRROR registry screen", "criteria": [ "Selected spontaneous supratentorial IPH being considered for minimally invasive evacuation", "Volume, NIHSS, premorbid mRS, and GCS thresholds are version-sensitive and must be checked against the active registry protocol before use", "No underlying vascular lesion", "Potential MIS timing within 24 hours of last known well or qualifying wake-up hemorrhage window" ], "action": "Do not let registry screening delay urgent surgical, trial, or stabilization decisions." } ], "safetyPause": { "title": "Before any surgical action", "items": [ "Stop at bedside for a time-out/safety pause.", "Confirm that Neurosurgery, the stroke service, and the ICU team agree on the plan.", "Do not present an operative plan as final until the cross-team agreement is explicit." ] }, "documentation": [ "If Neurosurgery recommends no procedure, document no current surgical indication within 24 hours.", "Document the caller, receiving consultant, closed-loop recipient, and agreed next step." ] }, "safePauseAttestation": "#STROKESAFEPAUSE" } }