Traumatic intracerebral hemorrhage: Difference between revisions
(Created page with "== Background == *Classification based on GCS **14-15: Mild **9-13: Moderate **3-8: Severe == Diagnosis == *Monitor for increased ICP **HA, N/V, sz, lethargy, HTN, b...") |
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==Management== | ==Management== | ||
*Pretreatment w/ lidocaine has not been shown to improve outcomes | |||
*[[Seizure Prophylaxis in Head Trauma]] | |||
*[[Management of Elevated Intracranial Pressure]] | |||
===Prevent further brain injury=== | |||
#Head of bed @ 30 degrees | |||
#Prevent: | |||
##Hypotension | |||
##Hypoxia | |||
##Anemia | |||
##Hyperthermia | |||
##Coagulopathy | |||
#[[Seizure Prophylaxis in Head Trauma]] | |||
===[[Increased ICP]]=== | |||
#Ensure adequate sedation (prevent gag reflex) | |||
#IVF to goal MAP >80 (maintains cerebral perfusion) | |||
#Mannitol | |||
##If SBP>90 | |||
###If SBP>90 in adults use hypertonic saline NaCl 5% 150ml over 10 min | |||
##Reduces ICP w/in 30min; duration of action of 6-8hr | |||
##Bolus 20% @ 0.25-1 gm/kg as rapid infusion | |||
##Monitor I+O to maintain euvolemia | |||
#Hyperventilation | |||
##No longer recommended as prophylactic intervention | |||
###Hyperventilation to PaCO2 <25 never indicated | |||
##Brief course only recommended if impending herniation (i.e., Cushing reflex) | |||
####Maintain PaCO2 28-35 (20 breaths/min) | |||
#Seizure | |||
##Treat immediately | |||
##Seizure prophylaxis reduces sz but does not improve long-term outcomes | |||
#Goal CPP ~60mmHg | |||
##If MAP <80, then CPP<60 | |||
###consider crystalloids or colloids (plasma if INR>1.3) | |||
###phenylephrine 10-100mcg/min, or other pressors prn | |||
###transfuse PRBCs, Hb>7 | |||
==See Also== | ==See Also== |
Revision as of 19:36, 10 January 2015
Background
- Classification based on GCS
- 14-15: Mild
- 9-13: Moderate
- 3-8: Severe
Diagnosis
- Monitor for increased ICP
- HA, N/V, sz, lethargy, HTN, bradycardia, agonal respirations, posturing
- Monitor for herniation
- Ipsilateral fixed and dilated pupil
- Contralateral motor paralysis
- B/l pinpoint pupils suggests opiate use or pontine lesion
Workup
Workup
- Consider head CT (rule out intracranial hemorrhage)
- Use validated decision rule to determine need
- Avoid CT in patients with minor head injury who are at low risk based on validated decision rules.[1]
- Consider cervical and/or facial CT
Differential Diagnosis
Intracranial Hemorrhage Types
- Intra-axial
- Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
- Traumatic intracerebral hemorrhage
- Extra-axial
- Epidural hemorrhage
- Subdural hemorrhage
- Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)
Concussion
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Management
- Pretreatment w/ lidocaine has not been shown to improve outcomes
- Seizure Prophylaxis in Head Trauma
- Management of Elevated Intracranial Pressure
Prevent further brain injury
- Head of bed @ 30 degrees
- Prevent:
- Hypotension
- Hypoxia
- Anemia
- Hyperthermia
- Coagulopathy
- Seizure Prophylaxis in Head Trauma
Increased ICP
- Ensure adequate sedation (prevent gag reflex)
- IVF to goal MAP >80 (maintains cerebral perfusion)
- Mannitol
- If SBP>90
- If SBP>90 in adults use hypertonic saline NaCl 5% 150ml over 10 min
- Reduces ICP w/in 30min; duration of action of 6-8hr
- Bolus 20% @ 0.25-1 gm/kg as rapid infusion
- Monitor I+O to maintain euvolemia
- If SBP>90
- Hyperventilation
- No longer recommended as prophylactic intervention
- Hyperventilation to PaCO2 <25 never indicated
- Brief course only recommended if impending herniation (i.e., Cushing reflex)
- Maintain PaCO2 28-35 (20 breaths/min)
- No longer recommended as prophylactic intervention
- Seizure
- Treat immediately
- Seizure prophylaxis reduces sz but does not improve long-term outcomes
- Goal CPP ~60mmHg
- If MAP <80, then CPP<60
- consider crystalloids or colloids (plasma if INR>1.3)
- phenylephrine 10-100mcg/min, or other pressors prn
- transfuse PRBCs, Hb>7
- If MAP <80, then CPP<60