Breathing, circulation is the key to emergency treatment of ICH
1. To ensure the maintenance of airway patency and oxygenation (oxygenation): the rapid deterioration of neurological function and consciousness will lead to loss of airway reflexes, requiring endotracheal intubation and mechanical ventilation, or will result in aspiration, hypoxemia, hypercapnia, so that cerebral vasodilation and increased intracranial pressure further. early after mechanical ventilation, respiratory rate and tidal volume of regulation should be maintained at PCO2 35mmHg or so, early hyperventilation, can not make PCO2 less than 28mmHg, in order to avoid vasoconstriction and deterioration of cerebral ischemia.
2. to maintain circulation.
3. Check whether the nervous system trauma signs and limitations
4. comorbidities prevention and treatment: adorned sores, compartment syndrome (compartment syndromes), and rhabdomyolysis.
caution
high blood pressure, high blood pressure may rupture or bleeding of the small arteries to rebleeding and hematoma expansion; over lower blood pressure will reduce cerebral perfusion pressure and increased brain damage, treatment should be weighed carefully.
1. patients with a history of hypertension, mean arterial pressure (MAP) should be maintained at 130mmHg.
(2) high intracranial pressure and intracranial pressure monitoring by cerebral perfusion pressure (MAPnICP) must be maintained at 70mmHg.
3. Mean arterial pressure in patients after surgery should not be less than 110mgHg.
4. hypotension: If the systolic blood pressure less than 90mmHg, it will damage the brain perfusion, the brain can cause serious watershed infarction, should be given to boost drug treatment.
5. drugs: hypertension in the emergency room, can be every 10 minutes, repeated intravenous pull Bello Chelsea (labetal), the dose from 10mg to 80mg. the best of hypertension in the ICU, continuous intravenous La Beiluo Chelsea, esmolol Los Chelsea (esnolo) or nicardipine (nicadipine) control to avoid the use of sodium nitroprusside, because there is cerebral vasodilation and increased ICP role.
commonly used antihypertensive drugs

mechanism of drug dose
anti
indications
La Beiluo Chelsea
alpha-1, beta-1, beta-2 receptor antagonist
intravenous 10-80mg/10 minutes, maximum dose 300mg;
intravenous infusion of 0.5-2.0 / min
bradycardia
congestive heart failure, bronchospasm
esmolol
Los Chelsea
beta-1 receptor antagonist
0.5mg/Kg
intravenous infusion 50-300mg/Kg / points
bradycardia
congestive heart failure
bronchospasm
nicardipine
L-type calcium antagonist (dihydropyridine)
infusion 5-15mg / h
severe aortic stenosis, myocardial ischemia

ACEI
enalapril intravenous 0.625mg,
intravenous infusion of 1.25-5mg / every 6 hours
angioneurotic edema

nitrogen vasodilator sodium nitroprusside (arteriovenous)
0.25-10mg/Kg / min ICP increase, myocardial ischemia, thiocyanate and cyanide poisoning
intracranial hypertension treatment
intracranial hypertension treatment, in principle, is to reduce intracranial pressure, what it means? different situations how different treatment of high intracranial pressure? should pay attention to what?
(a) The definition of high intracranial pressure ICP
standard: ICP is defined as intracranial pressure Elevated ICP> 20mmHg more than 5 minutes (20mmHg = 2.67kPa. ~ 2.65kPa = 270mmH2O)
(b) the processing target
ICP <20mmHg and cerebral perfusion pressure (CPP)> 70mmHg (CPP = MAP-ICP)
(c) processing means
1. osmosis (dehydration) drug treatment (osmotherapy): first-line therapy, should not be used for the prevention and treatment. progressive increase of ICP, hematoma with mass effect and clinical deterioration in patients given 20% mannose (0.25-0.5g/kg / 4 hours). because of its rebound phenomenon, mannitol up for 5 days In order to support the penetration of the gradient, which can be given furosemide (furosemide) hours per 2n8 10mg, serum osmolality must be measured twice a day, maintained at 310mOsm / L.
mannitol, glycerol and fructose than the slow onset and long duration , no rebound phenomenon, no hemolysis (hemolysis caused by salt fructose should be disabled).
2. controlled hyperventilation: dehydration and drug use can enhance and extend the effects. alone, efficacy can only be sustained Ji-hour, on the use of a short-term care patients.
3. barbiturate coma (barbiturate coma): pentobarbital (pentobarbital) intravenous injection of 5-20mg/kg, intravenous infusion of 2-4mg/kg / hour .
4. hypothermia: the body temperature to maintain 32.C-33.C.
5. do not recommend using corticosteroids: for it can cause high blood sugar, immune suppression, protein breakdown and wound healing problems.
( IV) acute increased intracranial pressure (ICP) for the treatment of
stupor, coma, or the performance of hernia patients, indications for surgical treatment, surgical treatment should be to: 1. .. 2.20 30 elevated head position rapid intravenous infusion of mannitol 1.0-1.5g/kg% .3. hyperventilation conditions may make PCO2 of 28-32mmHg.
(e) of intraventricular hemorrhage in the treatment of acute intracranial hypertension
ventricle bleeding can cause acute obstructive hydrocephalus, and traumatic bleeding the same patients in coma (Glasgow coma score less than 8 points) should be given to ICP monitoring and ventricular drainage, to maintain the following ICP in 20mg 60mg and cerebral perfusion pressure greater than . ventricular drainage for early brain stem herniation has rolled salvage life and reduce the effect of intracranial pressure, but the risk of causing intracranial infection Yan, 10 days before the infection is 10%.
intraventricular injection of thrombolytic agents such as urokinase (5000-2500IU) can accelerate the dissolution of blood clots, reduce catheter obstruction and chronic hydrocephalus, may improve the prognosis, but the risk of intracranial hemorrhage Yan, should be weighed against the use of the existing Phase II clinical trials in for this study.
another ultra-early application of hemostatic
Note: aminocaproic acid and tranexamic acid are all anti-fibrinolytic agent, a small sample of clinical trial results invalid.
4 hours application of hemostatic agents to stop bleeding and hematoma of the increased inhibition of recombinant activated coagulation factor VII (recombinant activated factor VII, rFVIIa):
1. for the strong hemostatic initiator (initiator). clotting factor used for the original drug VIII replacement therapy resistance in patients with hemophilia are also found in patients with normal coagulation system can improve clotting.
2. clinical trial results (Mayer SA et al. N Engl J Med; 2005,352:777): after the onset of 4 hours to give 40mg, 80mg and 160mg of rFVIIa to limit hematoma growth of 50%, reducing death and disability rates (38%), but severe thromboembolic events (myocardial infarction and cerebral infarction) increased (5%). FDA indications to be approved this phase III clinical trial (FAST trial) results.
ICH general processing
1. water and electrolyte balance:
(1) intravenous infusion of isotonic fluids can be used, such as 0.9% salt (about 1ml/kg/h).
(2) hypotonic fluids, such as 0.45% saline or 5% glucose disabled, due to the flow of water along the osmotic gradient lesions of the brain tissue, will increase cerebral edema and increased intracranial internal pressure.
(3) the liquid sugar should generally be avoided (except low blood sugar), high blood sugar damage in brain lesions.
(4) system with low osmolality (<280mmol/kg) should be active treatment, the use of mannitol or 3% hypertonic saline.
(5) normal blood volume status: should monitor fluid balance, central venous pressure and weight to be completed.
(6) 3% chloride / acetic acid of sodium (sodium chloride / acetate) hypertonic saline (1ml/kg/h): In a significant mass effect and perihematomal edema in patients with normal saline can be used to replace, to establish and maintain a high osmotic pressure condition (300-320mmol/kg ) and high sodium (150-155mEq / L), this can reduce the onset of ICP crisis Yan number of times to stop using the reduction should be gradual to avoid rebound edema and increased intracranial pressure; serum sodium concentration decreased speed not too fast within 24 hours can not exceed 12mEq / L, serum sodium to avoid a sudden reduction of brain damage, such as the dissolution of the Central Sui sheath disease.
(7) regular monitoring of electrolyte balance, especially in the use of dehydration therapy should be routine potassium , sodium correction should not be too fast.
2. the treatment of anti-epileptic seizures:
ICH 30 days after the clinical diagnosis of epilepsy risk Yan of 8%, status epilepticus seizures seen in 1-2% of patients . lobar hemorrhage is expected is expected early seizures independent factors.
(1) acute seizures: Should intravenous lorazepam (lorazepam) 0.05-0.1mg/kg or diazepam (diazepam, diazepam) 10mg , followed by intravenous phenytoin sodium in stupid or fosphenytoin, valproic acid or sodium.
(2) prophylaxis: learning from the experience of traumatic brain injury, bleeding on the screen, especially lobar hemorrhage, and mentally disorders , the first week to give preventive treatment, seizures can reduce the rate from 14% to 4%.
(3) prevention and treatment for 1 month, absence seizures can be discontinued.
non-convulsive epilepsy: ICH Continuous EEG abnormality in patients with 28% of patients with stupor or coma, 28% can be found in non-convulsive seizure or status epilepticus. EEG electrical activity of epilepsy patients are associated with deterioration of neurological symptoms and midline shift. conditional are available at 48 hours after ICH line EEG monitoring, non-convulsive seizures may be given midazolam (0.2mg/kg/h) treatment.
3. the maintenance of body temperature:
(1) ICH after the fever is very common, in particular, should be active after the treatment of intraventricular hemorrhage, or animal testing that is slightly elevated body temperature will increase the death of neurons. temperature above 38.3 ℃ should use drugs and physical cooling.
(2) the treatment of mild Low Temperature: learn cerebral infarction therapeutic effect of mild hypothermia, mild efficacy, complications are more, is not currently recommended for routine use. cooling means in addition to commonly used cooling blankets, cooling helmets and ice, there are surface adhesion cooling heat exchange catheter system and blood vessels can better maintain the temperature.
4. Nutrition: critically ill neurological patients, and all the same, ICH should be started 48 hours after enteral feeding to avoid malnutrition risk Yan. small nasal cavity duodenal feeding (nasoduodenal feeding) can reduce the risk of aspiration Yan the first week of using small nasal cavity in patients with duodenal feeding tube feeding than normal mortality rate decreased by 6% earlier than the late-placed percutaneous endoscopic gastric tube no significant effect.
5. prevention of deep vein thrombosis:
ICH in patients with deep vein thrombosis and pulmonary embolism risk Yan rate increased, due to paralysis and long-term fixed due. pulmonary embolism is caused by life’s complications, should be given to prevention. long stockings and have a preventive role in passive activities. there is a small clinical trial found that 2 days after the disease started to give small doses of subcutaneous heparin (5000 units, 2 times / day) can significantly reduce the complications, and does not increase intracranial bleeding. 2 days after onset, to give low molecular weight heparin (eg enoxaparin 40mg once a day) may be more secure.
6. the treatment of other medical problems: (1) Zao restless; (2) early rehabilitation the treatment.
summary
ICH Note
therapy treatment options
Note
avoid the use of sodium nitroprusside treatment of hypertension

saline treatment of high intracranial pressure
disabled fructose ; not recommended corticosteroids
application of hemostatic
rFVIIa indications for treatment of acute cerebral hemorrhage phase III clinical trials to be handled
disabled
generally hypotonic fluid; avoid sugary liquid; not recommended for routine treatment of mild hypothermia