IntracranialHemorrhage腦出課件(PPT 55頁(yè))

1、Intracranial Hemorrhage第1頁(yè)，共55頁(yè)。 Marc Dorfman, MD, FACEP, MACPEM Residency Program Director Resurrection Medical CenterChicago, ILMarc Dorfman, MD, FACEP, MACP第2頁(yè)，共55頁(yè)。Case Presentation57 year old femaleSudden onset, severe headacheTook ASA for reliefSlurred speechCollapsed第3頁(yè)，共55頁(yè)。Physical ExamT 99

2、.4 P52 BP 195/99 RR13Pupils-2 mm reactiveNeck-no JVD, bruitsCV-bradycardia, no murmurAbd-bs+, soft , nt/ndSkin-warm and dry第4頁(yè)，共55頁(yè)。Neurological ExamNeurological exam:no gag reflex, withdraws to pain, +4 DTR 第5頁(yè)，共55頁(yè)。GCSEyes-1Verbal-1Motor-4第6頁(yè)，共55頁(yè)。NIH Stroke ScaleNIH Stroke Scale第7頁(yè)，共55頁(yè)。NIHSS Sco

3、reStroke scale 25第8頁(yè)，共55頁(yè)。CT Scan第9頁(yè)，共55頁(yè)。NY Times第10頁(yè)，共55頁(yè)。Key Clinical QuestionsWhat 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?第11頁(yè)，共55頁(yè)。K

4、ey Clinical QuestionsWhich ICH patient require surgery?How does hemorrhage volume change over time? Does hemorrhage volume growth affect mortality?What are the new therapies being tested for this disease process?第12頁(yè)，共55頁(yè)。Intracranial HemorrhageEpidemiologyEtiologyDiagnosisTreatmentBP managementNeur

5、osurgical indicationsNew treatment modalities第13頁(yè)，共55頁(yè)。ICH Epidemiology30 day mortality: 35-52%50% of these in first 48 hoursOne-fifth of survivors are independent at 6 months7000 operations annually in USA to remove blood 第14頁(yè)，共55頁(yè)。ICH TypesEpiduralSubduralSubarachnoidIntraparencymalIntraventricula

6、rCerebellar第15頁(yè)，共55頁(yè)。Hypertensive ICHHypertensionEssentialEclampsiaSympathomimeticsCocaineAmphetaminesPhenylpropanolamine第16頁(yè)，共55頁(yè)。Hypertensive ICHBasal ganglia (50%)Contralateral hemiparesis, sensory loss, conjugate gazeLobar regions (20-50%)Contralateral hemiparesis or sensory loss, aphasia, negle

7、ct, or confusionThalamus (10-15%)Contralateral hemiparesis, sensory loss, gaze paresisPons (5-12%)Quadriparesis, facial weakness, decreased level consciousnessCerebellum (1-5%)Ataxia, miosis, gaze paresis第17頁(yè)，共55頁(yè)。Other ICH EtiologiesAmyloidTraumaVascular malformation-Avm, cavernoushemangiomasAneury

8、smTumorCoagulopathyVasculitis第18頁(yè)，共55頁(yè)。ICH PresentationHypertension (90%)Altered mental status (50%)Headache (40%) Seizures (6-7%)第19頁(yè)，共55頁(yè)。ICH DiagnosisCT scanCT scan is the most effective tool in the EDCT scan is excellent for imaging blood第20頁(yè)，共55頁(yè)。ICH Rx Key ConceptsTwo key concepts:Intracranial

9、 pressureElevated when ICP 20 mm HgCerebral perfusion pressureCPP=MAP-ICPMust maintain ICP 70 mm HgExample: MAP = 100, ICP = 20CPP in above example = 80 mmHg 第21頁(yè)，共55頁(yè)。Increased ICP TreatmentIntracranial Pressure (ICP): considered a major contributor to mortality when elevatedControlling ICP is cons

10、idered essentialOsmotherapyHyperventilationBarbiturate coma第22頁(yè)，共55頁(yè)。Clinical Case: ED RxPatient starts to vomitB/P 266/122RSILidocaine 100 mgsEtomadate 20 mgsSuccinylCholine 100 mgsMannitol 150 ccsElevate Head of Bed Hyperventilation to pCO25-30第23頁(yè)，共55頁(yè)。Clinical Case: ED RxParalytics-Pancuronium 7

11、 mgBP management-NiprideSteroids-Decadron 10 mgs第24頁(yè)，共55頁(yè)。OsmotherapyOsmotherapy-MannitolReduces cerebral edema by decreasing cerebral fluid volumeRebound effect-use less than 5 days20% solution0.5-1.0 mg/kg maintain serum osmolarity 310-320 mOsm/L第25頁(yè)，共55頁(yè)。HOB ElevationElevate head of bed-decrease

12、ICPMechanical-helps drain blood by gravityDoes not allow blood to pool in cranium, which may occur if patient is left laying flat第26頁(yè)，共55頁(yè)。Endotracheal IntubationIntubation-not required, but airway protection and adequate ventilation are necessaryRely on clinical suspicion, not GCSHyperventilation d

13、ecreases ICP pCO2 should be kept around 30-35Beneficial effect of sustained hyperventilation is not proven第27頁(yè)，共55頁(yè)。ParalyticsRecommended in order to prevent increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT, all of which may cause ICP spikesICP s

14、pikes associated with poorer outcome, especially in setting of elevated ICP第28頁(yè)，共55頁(yè)。ICP MonitorsAHA 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第29頁(yè)，共55頁(yè)。BP ManagementLower blood pressure to decrease r

15、isk of ongoing bleeding from ruptured small arteriesOveraggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injuryEspecially true with elevated ICP第30頁(yè)，共55頁(yè)。BP ManagementAHA recommends blood pressure be maintained below a mean arterial pressure of 130 mm

16、Hg in persons with a history of hypertensionIf there is an ICP monitor:ICP should be kept 70 mm Hg第31頁(yè)，共55頁(yè)。BP ManagementAvoid hypotensionIf systolic BP drops to less than 90 mmHg, consider judicious fluid boluses and/or start pressors第32頁(yè)，共55頁(yè)。BP ManagementLabetalol20 mg IV, followed by 40 80 mg IV

17、 q10 minTitrate to BP or max 300 mgs adminNipride0.5-1.0 mics/kg/minTheoretically can increase cerebral blood flow and thereby intracranial pressure第33頁(yè)，共55頁(yè)。BP ManagementTreatment should be started within 6 hours of symptom onsetA Prospective Multicenter Study to Evaluate the Feasibility and Safety

18、 of Aggressive Antihypertensive Treatment in Patients with Acute Intracerebral HemorrhageJournal of Intensive Care Medicine, Vol 20, No 1Burke, Dorfman-not yet published第34頁(yè)，共55頁(yè)。Fever ManagementElevated temperatures can increase the degree of ischemic injury. Etiologies include infection, neuronal

19、injury, SIRSStudies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation. Treat temperture 38.5 CAcetaminophen or a cooling blanket best options. 第35頁(yè)，共55頁(yè)。Seizure TherapyNeuronal injury may lead to seizuresNonconvulsive seizures may contribute to coma

20、 in up to 10% of neurocritical patientsConsider prophylactic antiepileptic therapy in setting of ICHLobar hemorrhage-35% seizure rateFosphenytoin or phenytoin第36頁(yè)，共55頁(yè)。Medical TherapyEuvolemiaIsotonic crystalloid solutionsElectrolyte abnormalitiesCorrect deficitsAcid/base disordersCorrect them if pr

21、esentSteroids-no benefit第37頁(yè)，共55頁(yè)。Blood Clot第38頁(yè)，共55頁(yè)。ICH Hemorrhage GrowthUntil recently, bleeding in patients with ICH was thought to be completed within minutes of onsetSeveral small studies describe a few patients who had an increase in the volume of parenchymal hemorrhage on repeated CT scans第3

22、9頁(yè)，共55頁(yè)。ICH Hemorrhage VolumeOld concept-Hemorrhage static process; bleeding complete in a minutesNew concept-Hemorrhage is dynamic; process continues for several hours第40頁(yè)，共55頁(yè)。ICH Hemorrhage GrowthEarly Hemorrhage Growth in Patients With Intracerbral HemorrhageBrott, Broderick, KothariStroke Vol 2

23、8, 1 January 1998第41頁(yè)，共55頁(yè)。ICH Growth: Study PurposeProspectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to neurological deterioration第42頁(yè)，共55頁(yè)。ICH Growth Study Design102 patientsCT scan 3 hours and 24 hours38% patients with

24、33% growth in volume of parenchymal hemorrhage第43頁(yè)，共55頁(yè)。ICH Growth: Conclusions Substantial early hemorrhage growth in patients with with intracerebral hemorrhage is common and is associated with neurological deterioration.Randomized treatment trials are needed to determine whether this ongoing blee

25、ding and frequent neurological deterioration can be improved第44頁(yè)，共55頁(yè)。ICH Factor VIIa StudySafety and Feasibility of Recombinant Factor VIIa for Acute Intracerebral HemorrhageMayer, Nikolai, BrunStroke, Jan 2005, 36(1) p74-9第45頁(yè)，共55頁(yè)。ICH Factor VIIa Study PurposeFactor VIIa-promotes clotting-know to

26、 do so in hemophiliacsActivated factor VII promotes hemostasis at sites of vascualr injury and may minimize hematoma grwoth in ICH第46頁(yè)，共55頁(yè)。ICH Factor VIIa Study Design48 subjectsRandomized double blind placebo controlledEscalating doses of factor VIIEndpoint-frequency of adverse events第47頁(yè)，共55頁(yè)。ICH

27、 Factor VIIa Study ConclusionPhase II trialNo major safety concernsLarger study needed to determine if factor VII can safely and effectively limit ICH growth第48頁(yè)，共55頁(yè)。ED Patient ManagementNeurosurgery consultedEVD placed in the EDPatient taken to the OR for evacuation of hematomaBP-119/79 P-92 RR-12

28、第49頁(yè)，共55頁(yè)。Patient OutcomeNext day: brain flow studiesPatient declared brain deadPatient extubated第50頁(yè)，共55頁(yè)。ICH Surgical IndicationsCerebellar hemorrhage 3 cm who are deteriorating or with brain stem compression and hydrocephalus from ventricular obstructionVascular malformation if lesion is surgically accessible and patient has chance for goo