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Marc Dorfman, MD, FACEP, MACP 1 Intracerebral Hemorrhage.

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1 Marc Dorfman, MD, FACEP, MACP 1 Intracerebral Hemorrhage

2 Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL Marc Dorfman, MD, FACEP, MACP

3 3 Case Presentation 57 year old female57 year old female Sudden onset, severe headacheSudden onset, severe headache Took ASA for reliefTook ASA for relief Slurred speechSlurred speech CollapsedCollapsed

4 Marc Dorfman, MD, FACEP, MACP 4 Physical Exam T 99.4 P52 BP 195/99 RR13T 99.4 P52 BP 195/99 RR13 Pupils-2 mm reactivePupils-2 mm reactive Neck-no JVD, bruitsNeck-no JVD, bruits CV-bradycardia, no murmurCV-bradycardia, no murmur Abd-bs+, soft, nt/ndAbd-bs+, soft, nt/nd Skin-warm and drySkin-warm and dry

5 Marc Dorfman, MD, FACEP, MACP 5 Neurological Exam Neurological exam:Neurological exam: no gag reflex, withdraws to pain, +4 DTRno gag reflex, withdraws to pain, +4 DTR

6 Marc Dorfman, MD, FACEP, MACP 6 GCS Eyes-1Eyes-1 Verbal-1Verbal-1 Motor-4Motor-4

7 NIH Stroke Scale

8 Marc Dorfman, MD, FACEP, MACP 8 NIHSS Score Stroke scale 25Stroke scale 25

9 CT Scan

10 Marc Dorfman, MD, FACEP, MACP 10 Key Clinical Questions What's the optimal ED management of a patient with ICH?What's the optimal ED management of a patient with ICH? What are the goals of BP management?What are the goals of BP management? Why is ICP important?Why is ICP important? What are the optimal strategies for managing ICP?What are the optimal strategies for managing ICP? What other treatment modalities are available to the ED physician?What other treatment modalities are available to the ED physician?

11 Marc Dorfman, MD, FACEP, MACP 11 Key Clinical Questions Which ICH patient require surgery?Which ICH patient require surgery? How does hemorrhage volume affect mortality?How does hemorrhage volume affect mortality? What are the new therapies being tested for this disease process?What are the new therapies being tested for this disease process?

12 NY Times

13 Marc Dorfman, MD, FACEP, MACP 13 Mission Statement ICH is a cause of significant mortality and morbidity. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical and medical managements of patients with ICH. No consistently efficacious strategies have been identified in such investigations. Management of ICH unfortunately remains heterogeneous across institutions, and continues to suffer from the lack of proven medical and surgical effectiveness.ICH is a cause of significant mortality and morbidity. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical and medical managements of patients with ICH. No consistently efficacious strategies have been identified in such investigations. Management of ICH unfortunately remains heterogeneous across institutions, and continues to suffer from the lack of proven medical and surgical effectiveness. Update on management of intracerebral hemorrhage; Neurosurgery Focus 15;

14 Algorithm Qureshi A, Tuhrim S: Spontaneous Intracerebral Hemorrhage; NEJM, Vol 344, No 19 May 10, 2001;

15 Marc Dorfman, MD, FACEP, MACP 15 Intracranial Hemorrhage DiagnosisDiagnosis TreatmentTreatment ICPICP BP managementBP management Medical managementMedical management Neurosurgical indicationsNeurosurgical indications New treatment modalitiesNew treatment modalities

16 Marc Dorfman, MD, FACEP, MACP 16 ICH Epidemiology 30 day mortality: 30-40%30 day mortality: 30-40% 50% of these in first 48 hours50% of these in first 48 hours One-fifth of survivors are independent at 6 monthsOne-fifth of survivors are independent at 6 months 7000 operations annually in USA to remove blood7000 operations annually in USA to remove blood

17 Marc Dorfman, MD, FACEP, MACP 17 ICH Presentation Hypertension (90%)Hypertension (90%) Altered mental status (50%)Altered mental status (50%) Headache (40%)Headache (40%) Seizures (6-7%)Seizures (6-7%)

18 ICH Diagnosis CT scanCT scan CT scan is the most effective tool in the ED CT scan is excellent for imaging blood

19 Marc Dorfman, MD, FACEP, MACP 19 Clinical Case: ED Rx Patient starts to vomitPatient starts to vomit B/P 266/122B/P 266/122 RSIRSI Lidocaine 100 mgsLidocaine 100 mgs Etomadate 20 mgsEtomadate 20 mgs Succinylcholine 100 mgsSuccinylcholine 100 mgs Mannitol 150 ccsMannitol 150 ccs Elevate Head of BedElevate Head of Bed Hyperventilation to pCO 2 -30Hyperventilation to pCO 2 -30

20 Marc Dorfman, MD, FACEP, MACP 20 Clinical Case: ED Rx Paralytics-Pancuronium 7 mgParalytics-Pancuronium 7 mg BP management-NiprideBP management-Nipride Steroids-Decadron 10 mgsSteroids-Decadron 10 mgs

21 Marc Dorfman, MD, FACEP, MACP 21 Initial ED Therapy Resuscitation of the patient- regardless of ICPResuscitation of the patient- regardless of ICP Assume elevated ICP in head injury/altered MS patientAssume elevated ICP in head injury/altered MS patient ABCs-as all good ED physician would doABCs-as all good ED physician would do

22 Marc Dorfman, MD, FACEP, MACP 22 Key Concept Cerebral blood flow:Cerebral blood flow: 1. Intracranial pressure Elevated when ICP >20 mm HgElevated when ICP >20 mm Hg 2. Cerebral perfusion pressure CPP=MAP-ICPCPP=MAP-ICP Maintain CPP > 70 mm HgMaintain CPP > 70 mm Hg Example: MAP = 100, ICP = 20Example: MAP = 100, ICP = 20 CPP in above example = 80 mmHgCPP in above example = 80 mmHg

23 Marc Dorfman, MD, FACEP, MACP 23 Increased ICP Risk Intracranial Pressure (ICP): considered a major contributor to mortality when elevatedIntracranial Pressure (ICP): considered a major contributor to mortality when elevated Correlation between elevated ICP and poor outcomeCorrelation between elevated ICP and poor outcome Increased risk ofIncreased risk of HerniationHerniation Decreased Cerebral perfusionDecreased Cerebral perfusion

24 Marc Dorfman, MD, FACEP, MACP 24 Increased ICP Treatment Controlling ICP is considered essential OsmotherapyOsmotherapy HyperventilationHyperventilation Barbiturate comaBarbiturate coma

25 Marc Dorfman, MD, FACEP, MACP 25 Clinical ICP Assessment For those without access to emergent ICP monitorsFor those without access to emergent ICP monitors Pupils size and reactivityPupils size and reactivity Neurological status- deterioration vs. improvementNeurological status- deterioration vs. improvement

26 Marc Dorfman, MD, FACEP, MACP 26 NIH Stroke Scale

27 Marc Dorfman, MD, FACEP, MACP 27 ICP Monitors GCS less than 9GCS less than 9 All patients whose condition is thought to be deteriorating due to elevated ICPAll patients whose condition is thought to be deteriorating due to elevated ICP Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999,

28 Marc Dorfman, MD, FACEP, MACP 28 Osmotherapy Osmotherapy-MannitolOsmotherapy-Mannitol Reduces ICP by decreasing cerebral fluid volumeReduces ICP by decreasing cerebral fluid volume Rebound effect-use less than 5 daysRebound effect-use less than 5 days Intermittent Bolus-not continuous infusionIntermittent Bolus-not continuous infusion mg/kg maintain serum osmolarity < mOsm/L mg/kg maintain serum osmolarity < mOsm/L Renal failureRenal failure Volume depletion (make sure patient has a Foley)Volume depletion (make sure patient has a Foley)

29 Marc Dorfman, MD, FACEP, MACP 29 HOB Elevation Elevate head of bed-decrease ICPElevate head of bed-decrease ICP Mechanical-helps drain blood by gravityMechanical-helps drain blood by gravity Keep neck in neutral positionKeep neck in neutral position Do not obstruct venous outflowDo not obstruct venous outflow Do not allow blood to pool in cranium, which may occur if patient is left laying flatDo not allow blood to pool in cranium, which may occur if patient is left laying flat

30 Marc Dorfman, MD, FACEP, MACP 30 Endotracheal Intubation Intubation-not required, but airway protection and adequate ventilation are necessaryIntubation-not required, but airway protection and adequate ventilation are necessary Rely on clinical suspicion, not GCSRely on clinical suspicion, not GCS Decreases ICP by decreasing CBFDecreases ICP by decreasing CBF pCO 2 should be kept around 30-35pCO 2 should be kept around Avoid PCO 2 less than 30Avoid PCO 2 less than 30 Decrease CBF to ischemia without further lowering ICPDecrease CBF to ischemia without further lowering ICP Beneficial effect of sustained hyperventilation is not provenBeneficial effect of sustained hyperventilation is not proven

31 Marc Dorfman, MD, FACEP, MACP 31 Lidocaine 1.5 mgs/kg1.5 mgs/kg Depresses cough reflexDepresses cough reflex Blocks increases in ICP of intubated patients with space occupying lesionsBlocks increases in ICP of intubated patients with space occupying lesions Give 3 minutes before laryngoscopyGive 3 minutes before laryngoscopy Lev, R, Rosen,Pp; Prophylactic Lidocaine Use Preintubation: A review: JOEM Vol 12 No

32 Marc Dorfman, MD, FACEP, MACP 32 Paralytics/Sedation Recommended:Recommended: prevents increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETTprevents increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT Avoids ICP spikes-elevated ICP correlated to poor outcomeAvoids ICP spikes-elevated ICP correlated to poor outcome

33 Marc Dorfman, MD, FACEP, MACP 33 Barbituate Coma Lowers ICP via lowering Cerebral metabolismLowers ICP via lowering Cerebral metabolism Use when other therapies failUse when other therapies fail No evidence of improved outcomeNo evidence of improved outcome

34 Marc Dorfman, MD, FACEP, MACP 34 BP Management Lower blood pressure to decrease risk of ongoing bleeding from ruptured small arteriesLower blood pressure to decrease risk of ongoing bleeding from ruptured small arteries Thus increasing hemorrhage volumeThus increasing hemorrhage volume Overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injuryOveraggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injury Especially true with elevated ICPEspecially true with elevated ICP

35 Marc Dorfman, MD, FACEP, MACP 35 SBP and ICH Incidence Incidence Rate/100,000 Systolic Blood Pressure (mmHg)

36 Marc Dorfman, MD, FACEP, MACP 36 BP Management Maintain blood pressure below a mean arterial pressure of 130 mm Hg in persons with a history of hypertensionMaintain blood pressure below a mean arterial pressure of 130 mm Hg in persons with a history of hypertension If there is an ICP monitor:If there is an ICP monitor: ICP should be kept < 20 m HgICP should be kept < 20 m Hg Cerebral perfusion pressure (MAP- ICP) should be kept > 70 mm HgCerebral perfusion pressure (MAP- ICP) should be kept > 70 mm Hg Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999,

37 Marc Dorfman, MD, FACEP, MACP 37 BP Management LabetalolLabetalol Repetitive I.V. boluses of mg q. 10 min or constant infusion of mg/minRepetitive I.V. boluses of mg q. 10 min or constant infusion of mg/min NicardipineNicardipine 5-15 mg/hr I.V. infusion5-15 mg/hr I.V. infusion Update on management of intracerebral hemorrhage; Neurosurg Focus 15;

38 Marc Dorfman, MD, FACEP, MACP 38 Nipride NiprideNipride mics/kg/min mics/kg/min Theoretically can increase cerebral blood flow and thereby intracranial pressureTheoretically can increase cerebral blood flow and thereby intracranial pressure

39 Marc Dorfman, MD, FACEP, MACP 39 BP Management Avoid hypotensionAvoid hypotension If systolic BP drops to less than 90 mmHgIf systolic BP drops to less than 90 mmHg fluid boluses-isotonic saline or colloidsfluid boluses-isotonic saline or colloids PressorsPressors Phenylephrine, dopamine, NorepinephrinePhenylephrine, dopamine, Norepinephrine Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999,

40 Hypotension Do not let Systolic BP fall below 90Do not let Systolic BP fall below 90 HypoxemiaHypoxemia Deleterious outcome 717 patients prospectively collected data set from Traumatic Coma Data bankDeleterious outcome 717 patients prospectively collected data set from Traumatic Coma Data bank May be more important than hypertensionMay be more important than hypertension

41 Marc Dorfman, MD, FACEP, MACP 41 Cerebral Blood Flow Neurology: July,

42 Marc Dorfman, MD, FACEP, MACP 42 Cerebral Blood Flow

43 Marc Dorfman, MD, FACEP, MACP 43 CBF: Conclusions In patients with small to medium sized acute ICH, autoregulation of CBF was preserved with arterial pressure reductions.In patients with small to medium sized acute ICH, autoregulation of CBF was preserved with arterial pressure reductions. Qureshi;Critical Care Medicine. 27(5): , May 1999-Qureshi;Critical Care Medicine. 27(5): , May mongrel dogs18 mongrel dogs Reduction of MAP within normal autoregulatory limits of CPP had no adverse outcome on ICP or regional blood flowReduction of MAP within normal autoregulatory limits of CPP had no adverse outcome on ICP or regional blood flow

44 Marc Dorfman, MD, FACEP, MACP 44 BP Management Treatment should be started within 6 hours of symptom onsetTreatment 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 HemorrhageA 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 1Journal of Intensive Care Medicine, Vol 20, No 1 Burke, Dorfman-not yet publishedBurke, Dorfman-not yet published

45 Marc Dorfman, MD, FACEP, MACP 45 Fever Management Elevated temperatures can increase the degree of ischemic injury.Elevated temperatures can increase the degree of ischemic injury. Etiologies include infection, neuronal injury, SIRSEtiologies include infection, neuronal injury, SIRS Studies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation.Studies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation. Treat temperature > 38.5˚ CTreat temperature > 38.5˚ C Acetaminophen or a cooling blanket best options.Acetaminophen or a cooling blanket best options.

46 Seizure Therapy Neuronal injury may lead to seizuresNeuronal injury may lead to seizures Nonconvulsive seizures may contribute to coma in up to 10% of patientsNonconvulsive seizures may contribute to coma in up to 10% of patients Consider prophylactic antiepileptic therapy in setting of ICHConsider prophylactic antiepileptic therapy in setting of ICH Lobar hemorrhage-35% seizure rateLobar hemorrhage-35% seizure rate Fosphenytoin or phenytoinFosphenytoin or phenytoin Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999,

47 Marc Dorfman, MD, FACEP, MACP 47 Seizure Therapy No consensus exists on when to withdraw anticonvulsant therapyNo consensus exists on when to withdraw anticonvulsant therapy If no seizure activity-withdraw at one monthIf no seizure activity-withdraw at one month Fewel: Spontaneous Intracerebral Hemorrhage: A Review; Neurosurg Focus 15 (4), 2003

48 Marc Dorfman, MD, FACEP, MACP 48 Medical Therapy EuvolemiaEuvolemia Isotonic crystalloid solutionsIsotonic crystalloid solutions Electrolyte abnormalitiesElectrolyte abnormalities Correct deficitsCorrect deficits Glucose management- >140 start insulinGlucose management- >140 start insulin

49 Marc Dorfman, MD, FACEP, MACP 49 Medical Therapy ABGABG Correct hypoxemia, hypercapniaCorrect hypoxemia, hypercapnia Correct acid/base disordersCorrect acid/base disorders CoagulopathyCoagulopathy Correct INRCorrect INR Correct Platelet countsCorrect Platelet counts

50 Marc Dorfman, MD, FACEP, MACP 50 Steroids ControversialControversial Three studies (159 patients)-no benefitThree studies (159 patients)-no benefit 1.Tellez H, Bauer RB: Dexamethasone as treatment in cerebrovascular disease. 1. A controlled study in intracerebral hemorrhage. Stroke 4:541– 546, 1973 (40) 2.Poungvarin N, Bhoopat W, Viriyavejakul A, et al: Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 316:1229–1233, 1987 (93) 3.Desai P, Prasad K. Dexamethasone is not necessarily unsafe in Primary Supratentorial Cerebral Hemorrhage. J Neurol Neurosurg Psychiatry. 1998;65: (26) Neurosurgerical literatureNeurosurgerical literature Use when evidence of vasogenic edema and mass effectUse when evidence of vasogenic edema and mass effect Update on management of intracerebral hemorrhage; Neurosurg Focus 15;

51 Marc Dorfman, MD, FACEP, MACP 51 Blood Clot

52 Marc Dorfman, MD, FACEP, MACP 52 ICH Hemorrhage Volume Old concept-Hemorrhage static process; bleeding complete in a minutesOld concept-Hemorrhage static process; bleeding complete in a minutes New concept-Hemorrhage is dynamic; process continues for several hoursNew concept-Hemorrhage is dynamic; process continues for several hours

53 Marc Dorfman, MD, FACEP, MACP 53

54 Marc Dorfman, MD, FACEP, MACP 54 ICH Growth Study Design 103 patients103 patients CT scan baseline 1 and 20 hoursCT scan baseline 1 and 20 hours Positive-increase hemorrhage 33%Positive-increase hemorrhage 33% 38% patients with > 33% growth in volume of parenchymal hemorrhage38% patients with > 33% growth in volume of parenchymal hemorrhage

55 Marc Dorfman, MD, FACEP, MACP 55

56 Marc Dorfman, MD, FACEP, MACP 56 Hemorrhage Volume Quick and dirty methodQuick and dirty method ABC/2ABC/2 A-greatest hemorrhage diameter by CTA-greatest hemorrhage diameter by CT B-diameter 90 degrees to AB-diameter 90 degrees to A C-approximate number of CT slices with hemorrhage multiplied by slice thickness in cmC-approximate number of CT slices with hemorrhage multiplied by slice thickness in cm L Schwamm; Guidelines for Emergency Department Management of Brain Hemorrhage 2, 2004

57 Marc Dorfman, MD, FACEP, MACP 57 Hematoma Volume Calculation Formula for volume of an ellipsoidFormula for volume of an ellipsoid 4/3Л (A/2)(B/2)(C/2)4/3Л (A/2)(B/2)(C/2) Simplified ABC/2Simplified ABC/2

58 Marc Dorfman, MD, FACEP, MACP 58 CT Scan A B A (11cm)-greatest hemorrhage diameter B(4cm)-Diaemter at 90degrees C-2mm slices,8 slices 11x4x0.16/2=35.2 mls

59 Prognosis WorseWorse Volume > 60 cm 3 and GCS 60 cm 3 and GCS < 9 91% dead at 30 days91% dead at 30 days Patients with volume over 30 cm 3 only 1 / 71 independent at 30 daysPatients with volume over 30 cm 3 only 1 / 71 independent at 30 days Intraventricular extensionIntraventricular extension BetterBetter Volume < 30 cm 3 and GCS 9 or higherVolume < 30 cm 3 and GCS 9 or higher 19% dead at 30 days19% dead at 30 days (Broderick, Stroke)

60 Marc Dorfman, MD, FACEP, MACP 60 BP & Hemorrhage Volume Ohwaki, k Yano E: Blood Pressure management in Acute Intracerebral Hemorrhage: Stroke 2004;35:1364

61 Marc Dorfman, MD, FACEP, MACP 61 BP & Hemorrhage Volume 76 patients76 patients Hemetoma enlargement in 16 patientsHemetoma enlargement in 16 patients Elevated BP increases the risk of hematoma enlargementElevated BP increases the risk of hematoma enlargement Ohwaki, k Yano E: Blood Pressure management in Acute Intracerebral Hemorrhage: Stroke 2004;35:1364

62 Marc Dorfman, MD, FACEP, MACP 62 Rec Factor VIIa-Coumadin

63 Marc Dorfman, MD, FACEP, MACP 63 ED Patient Management Neurosurgery consultedNeurosurgery consulted EVD placed in the EDEVD placed in the ED Patient taken to the OR for evacuation of hematomaPatient taken to the OR for evacuation of hematoma BP-119/79 P-92 RR-12BP-119/79 P-92 RR-12

64 Marc Dorfman, MD, FACEP, MACP 64 Patient Outcome Next day: brain flow studiesNext day: brain flow studies Patient declared brain deadPatient declared brain dead Patient extubatedPatient extubated

65 Marc Dorfman, MD, FACEP, MACP 65 ICH Surgical Outcome Arch Neuro. 1990;47:

66 Marc Dorfman, MD, FACEP, MACP 66 Surgical Outcome Arch Neuro. 1990;47:

67 Marc Dorfman, MD, FACEP, MACP 67 STICH Trial Lancet 2005;365:387-97

68 Marc Dorfman, MD, FACEP, MACP 68 STICH Trial-Methods

69 Marc Dorfman, MD, FACEP, MACP 69 STICH Data

70 Marc Dorfman, MD, FACEP, MACP 70 STICH Trial-Outcome

71 Marc Dorfman, MD, FACEP, MACP 71 STICH Trial Outcome

72 Marc Dorfman, MD, FACEP, MACP 72 STICH Conclusion Patients with spontaneous supratentorial intracerebral hemorrhage in neurosurgical units show no overall benefit from early surgery when compared to initial conservative treatmentPatients with spontaneous supratentorial intracerebral hemorrhage in neurosurgical units show no overall benefit from early surgery when compared to initial conservative treatment

73 Marc Dorfman, MD, FACEP, MACP 73 ICH Surgical Indications Cerebellar hemorrhage > 3 cm who are deteriorating or with brain stem compression and hydrocephalus from ventricular obstructionCerebellar 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 outcomeVascular 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 deterioratingYoung patients with a moderate or large lobar hemorrhage who are clinically deteriorating

74 Marc Dorfman, MD, FACEP, MACP 74 Non-Surgical ICH Pts Small Hemorrhages (10 cm 3 )Small Hemorrhages (10 cm 3 ) Minimal neurological deficitsMinimal neurological deficits GCS < 4 (excluding cerebellar hemorrhage with brain stem compression)GCS < 4 (excluding cerebellar hemorrhage with brain stem compression)

75 Marc Dorfman, MD, FACEP, MACP 75 Poor Outcome Risk Factors Large or increasing volume of hematomaLarge or increasing volume of hematoma Low GCS on admissionLow GCS on admission Interventricular clot extension and/or hydrocehalusInterventricular clot extension and/or hydrocehalus Anticoagulation agentsAnticoagulation agents Relative edemaRelative edema Update on management of intracerebral hemorrhage; Neurosurg Focus 15;

76 Marc Dorfman, MD, FACEP, MACP 76 What Can We Do? Optimal medical managementOptimal medical management Stop the bleedingStop the bleeding Factor VIIFactor VII Call your NeurosurgeonCall your Neurosurgeon I have this patient…you do not need to come inI have this patient…you do not need to come in

77 Marc Dorfman, MD, FACEP, MACP 77 Stroke Centers Hospitals should have systems in place to care for stroke patientsHospitals should have systems in place to care for stroke patients ED, Radiology, Neurology/Neurosurgery, Primary Care, RehabED, Radiology, Neurology/Neurosurgery, Primary Care, Rehab JACO lists Core MeasuresJACO lists Core Measures ASA, Dysphagia, DVT prophylaxis, TPA considered, Lipid profile, smoking cessation, plan for rehab, stoke educationASA, Dysphagia, DVT prophylaxis, TPA considered, Lipid profile, smoking cessation, plan for rehab, stoke education Similar to CardiologySimilar to Cardiology

78 Marc Dorfman, MD, FACEP, MACP 78 Key Learning Points For management guidelines.For management guidelines. Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999, Management and Prognosis of Severe Traumatic Brain Injury-a joint project of the Brain Trauma Foundation and the American Association of Neurosurgeons, 2000Management and Prognosis of Severe Traumatic Brain Injury-a joint project of the Brain Trauma Foundation and the American Association of Neurosurgeons, 2000

79 Marc Dorfman, MD, FACEP, MACP 79 Key Learning Points CT scan is the most important tool in your diagnostic toolbox Manage blood pressure, noting that guidelines are variableManage blood pressure, noting that guidelines are variable Aggressively manage fever and seizuresAggressively manage fever and seizures Consider hyperventilation and paralytics in setting of increased ICP and deteriorationConsider hyperventilation and paralytics in setting of increased ICP and deterioration

80 Marc Dorfman, MD, FACEP, MACP 80 Key Learning Points Most ICH patients are non-surgicalMost ICH patients are non-surgical Consult your neurosurgeon earlyConsult your neurosurgeon early Steroids-no benefitSteroids-no benefit There are promising new therapies such as Factor VII on the horizonThere are promising new therapies such as Factor VII on the horizon

81 Questions?? Marc Dorfman, MD Questions?? Marc Dorfman, MD ferne_acep_2005_spring_dorfman_ich_edrx 3/2/2005 9:45:12 AM Marc Dorfman, MD, FACEP, MACP


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