Click here to load reader

Intracranial Hemorrhage

  • View
    63

  • Download
    1

Embed Size (px)

DESCRIPTION

Intracranial Hemorrhage. Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL. Marc Dorfman, MD, FACEP, MACP. Case Presentation. 57 year old female Sudden onset, severe headache Took ASA for relief Slurred speech Collapsed. Physical Exam. - PowerPoint PPT Presentation

Text of Intracranial Hemorrhage

Intracranial HemorrhageIntracranial Hemorrhage
EM Residency Program Director
1
54
54
Case Presentation
Physical Exam
Pupils-2 mm reactive
Neck-no JVD, bruits
CV-bradycardia, no murmur
Abd-bs+, soft , nt/nd
Skin-warm and dry
Neurological Exam
Neurological exam:
Marc Dorfman, MD, FACEP, MACP
GCS
Eyes-1
Verbal-1
Motor-4
NIH Stroke Scale
NIH Stroke Scale
NIHSS Score
CT Scan
NY Times
Key Clinical Questions
What are the most common etiologies and locations of ICH?
What are the goals of BP management?
What are the optimal strategies for managing ICP?
What other treatment modalities are available to the ED physcian?
Marc Dorfman, MD, FACEP, MACP
Key Clinical Questions
How does hemorrhage volume change over time?
Does hemorrhage volume growth affect mortality?
What are the new therapies being tested for this disease process?
Marc Dorfman, MD, FACEP, MACP
Intracranial Hemorrhage
ICH Epidemiology
One-fifth of survivors are independent at 6 months
7000 operations annually in USA to remove blood
Marc Dorfman, MD, FACEP, MACP
ICH Types
Hypertensive ICH
Hypertensive ICH
Lobar regions (20-50%)
Thalamus (10-15%)
Pons (5-12%)
Cerebellum (1-5%)
Other ICH Etiologies
ICH Presentation
Hypertension (90%)
ICH Diagnosis
CT scan
CT scan is the most effective tool in the ED
CT scan is excellent for imaging blood
Marc Dorfman, MD, FACEP, MACP
ICH Rx Key Concepts
Cerebral perfusion pressure
Example: MAP = 100, ICP = 20
CPP in above example = 80 mmHg
Marc Dorfman, MD, FACEP, MACP
Increased ICP Treatment
Intracranial Pressure (ICP): considered a major contributor to mortality when elevated
Controlling ICP is considered essential
Osmotherapy
Hyperventilation
Clinical Case: ED Rx
Patient starts to vomit
Clinical Case: ED Rx
Osmotherapy
Osmotherapy-Mannitol
Rebound effect-use less than 5 days
20% solution
Marc Dorfman, MD, FACEP, MACP
HOB Elevation
Elevate head of bed-decrease ICP
Mechanical-helps drain blood by gravity
Does not allow blood to pool in cranium, which may occur if patient is left laying flat
Marc Dorfman, MD, FACEP, MACP
Endotracheal Intubation
Rely on clinical suspicion, not GCS
Hyperventilation decreases ICP
Beneficial effect of sustained hyperventilation is not proven
Marc Dorfman, MD, FACEP, MACP
Paralytics
Recommended in order to prevent increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT, all of which may cause ICP spikes
ICP spikes associated with poorer outcome, especially in setting of elevated ICP
Marc Dorfman, MD, FACEP, MACP
ICP Monitors
AHA recommends ICP monitors in patients with a GCS less than 9 and all patients whose condition is thought to be deteriorating due to elevated ICP
Marc Dorfman, MD, FACEP, MACP
BP Management
Lower blood pressure to decrease risk of ongoing bleeding from ruptured small arteries
Overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injury
Especially true with elevated ICP
Marc Dorfman, MD, FACEP, MACP
BP Management
AHA recommends blood pressure be maintained below a mean arterial pressure of 130 mm Hg in persons with a history of hypertension
If there is an ICP monitor:
ICP should be kept < 20 m Hg
Cerbral perfusion pressure (MAP-ICP) should be kept > 70 mm Hg
Marc Dorfman, MD, FACEP, MACP
BP Management
Avoid hypotension
If systolic BP drops to less than 90 mmHg, consider judicious fluid boluses and/or start pressors
Marc Dorfman, MD, FACEP, MACP
BP Management
Labetalol
20 mg IV, followed by 40 80 mg IV q10 min
Titrate to BP or max 300 mgs admin
Nipride
Theoretically can increase cerebral blood flow and thereby intracranial pressure
Marc Dorfman, MD, FACEP, MACP
BP Management
Treatment should be started within 6 hours of symptom onset
A Prospective Multicenter Study to Evaluate the Feasibility and Safety of Aggressive Antihypertensive Treatment in Patients with Acute Intracerebral Hemorrhage
Journal of Intensive Care Medicine, Vol 20, No 1
Burke, Dorfman-not yet published
Fever Management
Etiologies include infection, neuronal injury, SIRS
Studies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation.
Treat temperture > 38.5 C
Marc Dorfman, MD, FACEP, MACP
Seizure Therapy
Neuronal injury may lead to seizures
Nonconvulsive seizures may contribute to coma in up to 10% of neurocritical patients
Consider prophylactic antiepileptic therapy in setting of ICH
Lobar hemorrhage-35% seizure rate
Medical Therapy
Blood Clot
ICH Hemorrhage Growth
Until recently, bleeding in patients with ICH was thought to be completed within minutes of onset
Several small studies describe a few patients who had an increase in the volume of parenchymal hemorrhage on repeated CT scans
Marc Dorfman, MD, FACEP, MACP
ICH Hemorrhage Volume
Marc Dorfman, MD, FACEP, MACP
ICH Hemorrhage Growth
Brott, Broderick, Kothari
Marc Dorfman, MD, FACEP, MACP
ICH Growth: Study Purpose
Marc Dorfman, MD, FACEP, MACP
ICH Growth Study Design
38% patients with > 33% growth in volume of parenchymal hemorrhage
Marc Dorfman, MD, FACEP, MACP
ICH Growth: Conclusions
Randomized treatment trials are needed to determine whether this ongoing bleeding and frequent neurological deterioration can be improved
Marc Dorfman, MD, FACEP, MACP
ICH Factor VIIa Study
Safety and Feasibility of Recombinant Factor VIIa for Acute Intracerebral Hemorrhage
Mayer, Nikolai, Brun
Factor VIIa-promotes clotting-know to do so in hemophiliacs
Activated factor VII promotes hemostasis at sites of vascualr injury and may minimize hematoma grwoth in ICH
Marc Dorfman, MD, FACEP, MACP
ICH Factor VIIa Study Design
48 subjects
Endpoint-frequency of adverse events
Phase II trial
No major safety concerns
Larger study needed to determine if factor VII can safely and effectively limit ICH growth
Marc Dorfman, MD, FACEP, MACP
ED Patient Management
Patient taken to the OR for evacuation of hematoma
BP-119/79 P-92 RR-12
Patient Outcome
Patient declared brain dead
ICH Surgical Indications
Cerebellar hemorrhage > 3 cm who are deteriorating or with brain stem compression and hydrocephalus from ventricular obstruction
Vascular malformation if lesion is surgically accessible and patient has chance for good outcome
Young patients with a moderate or large lobar hemorrhage who are clinically deteriorating
Marc Dorfman, MD, FACEP, MACP
Non-Surgical ICH Pts
Marc Dorfman, MD, FACEP, MACP
Key Learning Points
Hemorrhage volume can increase over time
CT scan is the most important tool in your diagnostic toolbox
Manage blood pressure, noting that guidelines are variable
Aggressively manage fever and seizures
Consider hyperventilation and paralytics in setting of increased ICP and deterioration
Marc Dorfman, MD, FACEP, MACP
Key Learning Points
Consult your neurosurgeon early
Steroids-no benefit
There are promising new therapies such as Factor VII on the horizon
265.psd
1
54
54

Search related