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
