So what are those steps in
managing patients with intracerebral hemorrhage?
So first and foremost, airway management as indicated.
So if your patient does not have a patent airway
or they're not able to protect their airway, then you want to
start thinking about performing intubation for those patients.
You wanna treat the elevated blood pressure.
As the blood pressure stays persistently elevated,
that area in the brain that’s bleeding is gonna keep bleeding.
So you wanna try and lower the blood pressure
so that bleeding stops or slows down.
The goal blood pressure is debatable
and there have been lots and lots of studies out there
that have looked what is the best blood pressure,
where do you want it to be?
Ultimately, between 140 to 160 systolic
is where you want the blood pressure to be.
You don’t wanna be too aggressive about it
because keep in mind that a majority of these patients
have chronically elevated blood pressure.
So you’re not taking care of someone
who has a normal perfect blood pressure.
And if you decrease the blood flow too much
that could potentially decrease the cerebral blood flow
in other areas of the brain.
So you wanna make sure you’re being cautious about decreasing
the blood pressure but not decreasing it too dramatically.
You also wanna reverse coagulopathy.
Historically, we used to have few medications
that would anticoagulate someone.
So it used to be someone who was on aspirin potentially
or Clavix and then warfarin or Coumadin
where are most common anticoagulation medications.
Now, there are novel or new oral anticoagulant medications.
And those can be tricky because
they don’t have any effect on the coagulation profile.
So for instance, if a patient is on warfarin that would be
reflected in the INR level. So the INR will be elevated.
If someone is on one of the newer oral anticoagulant medications,
those actually are not at all reflected in the coagulation studies.
So it can be very tricky to know
whether or not someone is on those.
Very key thing is to try and get that information from the pharmacy,
from the family member,
from the patient if they’re able to write it to you,
from the medical record.
Because if someone is on an anticoagulant,
you wanna make sure you reverse that.
And there’s different pathways for
reversing the different anticoagulation medications.
So for warfarin or Coumadin, you can give prothrombin concentrate
or you can give vitamin K or FFP.
And for the other oral anticoagulants, there’s a whole slow
of different pathways that you can give to reverse those.
But the key thing is finding out
whether or not someone is on it,
and if they are, take them to the next steps
to reverse that medication.
You also wanna reduce the intracranial pressure
if there’s concern that it's elevated.
That can be done either using Mannitol
which is a very potent diuretic.
You wanna be cautious about using that in the rare patient
that would have low blood pressure.
Because what that can do is
it can further drop the blood pressure.
You can give hypertonic saline for those patients
who have low blood pressure
and you can also hyperventilate the patient.
Now, what the Mannitol and hypertonic saline do
is they essentially take the fluid out of the brain.
I describe it that you’re taking a brain from being a grape
to making it into a raisin.
They’re essentially kind of
sucking some of the water out of the brain.
And by sucking some of the water out of the brain,
you’re making the size and the pressure in turn smaller.
Hyperventilation works by lowering the PCO2 levels
by lowering the carbon dioxide levels
which will in turn cause vasoconstriction
or constricting of the blood vessels in the brain.
Yeah you can really only hyperventilate your patient
if they’re on a ventilator machine.
You can’t just ask your patient to breathe more rapidly,
that won’t necessarily do it.
A key thing to remember with hyperventilation is you wanna
make sure that the PCO2 level, that carbon dioxide level,
doesn’t go down too dramatically.
Cause again if you lower that level too dramatically,
you can cause too much constriction of the blood vessels.
And if you cause too much constriction of the blood vessels,
then again, you’re in a situation where the brain
might not necessarily be getting enough blood flow.
The last thing you wanna do is you wanna get a Neurology consult.
Often times, these patients are quite ill
and need to be admitted to the hospital.
Under the Neurology service,
rarely will the neurosurgery team get involved
because there’s really not too much surgical process
that can be offered to these patients.
But generally, they need to be very closely watched
and to be monitored
and also will need physical therapy
to help them work on their disability.
And a lot of critical management
to get them through those initial phases.
Now, the mortality, like I mentioned, is quite high.
And their scoring system is based on the GCS, how large
the volume of the intracerebral hemorrhage is on the CT scan.
If there’s any blood in the ventricular system of the brain.
The location of the bleed, so is it infra versus supratentorial?
Supratentorial bleeds are bleeds that are in the upper portions
of the brain, the frontal lobe, the temporal lobe.
Infratentorial are bleeds that are
in the cerebellum and the brain stem.
And then the age. So 80 is generally the age cut off
in which the mortality increases over 80.