News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD
Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.
May 3, 2007 — The American Heart Association (AHA) and American Stroke Association have issued updated evidence-based guidelines for treatment of spontaneous intracerebral hemorrhage (ICH) in adults. The new recommendations, which update the first AHA guidelines for the management of spontaneous ICH published in 1999, are published in the May 3 Stroke ASAP issue and will appear in the June print issue of Stroke.

“The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage,” write Joseph Broderick, MD, FAHA, and colleagues from the AHA/American Stroke Association Stroke Council, High Blood Pressure Research Council, and Quality-of-Care Outcomes in Research Interdisciplinary Working Group. “In the past 6 years, 15 pilot and larger randomized medical and surgical trials for ICH/intraventricular hemorrhage (IVH) have been completed or are ongoing, as listed at the National Institute of Neurological Disorders and Stroke–funded Stroke Trials Directory; these are in addition to the ongoing phase III trial of recombinant activated factor VII (rFVIIa). The recent dramatic increase in clinical trials of ICH/IVH and the initial findings from these trials provide great hope for new and effective treatments for patients with ICH.”

The panel performed a formal literature search of MEDLINE through the end date of August 2006 and reviewed additional articles on related issues known to the writing committee. The AHA Stroke Council’s levels-of-evidence grading algorithm was used to grade each recommendation, and 5 expert peer reviewers and the members of the Stroke Council Leadership Committee reviewed the draft guidelines before release. An additional full update is planned in 3 years’ time.

These evidence-based guidelines offer recommendations for the diagnosis of ICH, the management of increased arterial blood pressure and intracranial pressure (ICP), the treatment of medical complications of ICH, and the prevention of recurrent ICH. Recent trials of recombinant activated factor VII to slow initial bleeding are reviewed.

The guidelines also provide recommendations for various surgical approaches for treatment of spontaneous ICH and discuss withdrawal-of-care and end-of-life issues in patients with ICH.

Recommendations for emergency diagnosis and evaluation of ICH are that ICH is a medical emergency, with frequent early, ongoing bleeding and progressive deterioration, severe clinical deficits, and subsequent high mortality and morbidity rates. Therefore, it should be promptly recognized and diagnosed (class I, level of evidence A). Computed tomography (CT) and magnetic resonance imaging (MRI) are each first-choice initial imaging options (I, A), but in patients in whom MRI is contraindicated, CT should be done.

Recommendations for initial medical therapy for ICH are as follows:

• Monitoring and treatment of patients should occur in an intensive care unit setting because ICH is an emergent condition with frequent elevations in ICP and blood pressure, frequent need for intubation and assisted ventilation, and multiple complicating medical issues (I, B).
• Treatment of elevated ICP should be balanced and graded, beginning with simple measures (eg, elevating the head of the bed, analgesia, and sedation). More aggressive therapies, such as osmotic diuretics (mannitol and hypertonic saline), drainage of cerebrospinal fluid with a ventricular catheter, neuromuscular blockade, and hyperventilation, usually require concomitant monitoring of ICP and blood pressure with a goal to maintain cerebral perfusion pressure above 70 mm Hg (IIa, B).
• Maintain euglycemia (IIa, B).
• Treat fever to normal body temperature (IIa, B).
• For patients who are clinically stable, early mobilization and rehabilitation are recommended (IIa, B).
• Manage blood pressure based on the presently available incomplete evidence, pending results from ongoing clinical trials of blood pressure intervention for ICH.
• In 1 moderate-sized phase 2 trial, treatment with recombinant activated factor VII within the first 3 to 4 hours after onset appeared to slow progression of bleeding. However, the efficacy and safety of this treatment must be confirmed in phase 3 trials before its use in ICH can be recommended outside of a clinical trial (IIb, B).
• Appropriate antiepileptic drugs should always be used for treatment of clinical seizures (I, B). Short-term use of prophylactic antiepileptic drugs soon after ICH onset may decrease the risk for early seizures in patients with lobar hemorrhage (IIb, C).

Recommendations for management of coagulation and fibrinolysis issues related to ICH are as follows:

• Use protamine sulfate to reverse heparin-associated ICH, with the dose depending on the time from cessation of heparin (I, B).
• To reverse the effects of warfarin, treat patients who have warfarin-associated ICH with intravenous vitamin K and with treatment to replace clotting factors (I, B).
• Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII normalize the laboratory elevation of the international normalized ratio very rapidly and with lower volumes of fluid than fresh frozen plasma. However, potential of thromboembolism is greater. Fresh frozen plasma is an option but is associated with greater volumes and much longer infusion times (II, B).
• The decision to restart antithrombotic therapy after ICH related to antithrombotic therapy depends on the risk for subsequent arterial or venous thromboembolism, the risk for recurrent ICH, and the patient’s overall condition (IIb, B).
• Treatment of patients with ICH caused by thrombolytic therapy includes urgent empirical therapies to replace clotting factors and platelets (IIb, B).

Recommendations for surgical approaches are as follows:

• Patients with cerebellar hemorrhage greater than 3 cm with neurologic deterioration or brain stem.
• Compression and/or hydrocephalus from ventricular obstruction should have surgical evacuation of the hemorrhage as soon as possible (I, B).
• Stereotactic infusion of urokinase into the clot cavity within 72 hours apparently reduces the clot burden and risk for death. However, rebleeding is more common and functional outcome is not improved (IIb, B).
• The usefulness of minimally invasive clot evacuation with a variety of mechanical devices and/or endoscopy needs further testing in clinical trials (IIb, B).
• Consider evacuation of supratentorial ICH by standard craniotomy for patients presenting with lobar clots within 1 cm of the surface (IIb, B).
• Routine evacuation of supratentorial ICH by standard craniotomy within 96 hours of ictus is not recommended (III, A).

“The first scientifically proven treatments for acute ICH are likely to become a reality during the next 5 years, and possibly sooner for some, such as rFVIIa,” the authors conclude. “New trials of antihypertensive therapy, surgical removal of ICH, and other adjunctive therapies are ongoing, but sustained efforts are needed to decrease the high morbidity and mortality rates associated with this deadly type of stroke.”

Stroke. Published online May 3, 2007.

Clinical Context

ICH accounts for up to 15% of first-time strokes and is associated with a 30-day mortality rate between 35% and 52%. Half of deaths related to ICH occur within the first 2 days, and the rate of mortality declines subsequently. Only 20% of patients with ICH can expect to maintain functional independence 6 months after the hemorrhage event.

Given these stark outcomes, appropriate initial management of spontaneous ICH is critical. The current guidelines from the AHA and American Stroke Association address this issue.

Study Highlights

• Classic symptoms of ICH include the sudden onset of a focal neurologic deficit, which progresses over minutes to hours. Vomiting is more common with ICH than with ischemic stroke or subarachnoid hemorrhage.
• Either CT or MRI may be used for initial neuroimaging of patients suspected of having ICH, but MRI may be more difficult to perform because of impaired consciousness, vomiting, or agitation.
• Recombinant factor VIIa has demonstrated promise in early trials in terms of reducing hematoma size, mortality, and 90-day disability among patients with ICH, but further testing is necessary to assess this therapy.
• If systolic blood pressure exceeds 200 mm Hg in a patient with ICH, continuous intravenous antihypertensive therapy should be considered. A target blood pressure of 160/90 mm Hg is reasonable.
• Treatment of elevated ICP should begin with conservative measures, such as elevation of the head of the bed, analgesia, and sedation. Further steps can include osmotic therapy with mannitol or hyperventilation, which can be associated with hypovolemia and decreased cerebral blood flow, respectively.
• Serum glucose levels should be lowered to at least less than 300 mg/dL after ICH.
• Patients with hemiparesis or hemiplegia following ICH should receive prophylaxis with intermittent pneumatic compression stockings. These patients may receive low-molecular-weight heparin after 3 to 4 days following cessation of bleeding.
• Patients with ICH who develop acute proximal venous thrombosis should be considered for acute placement of a vena cava filter.
• Patients who develop ICH while receiving warfarin should receive intravenous vitamin K. Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII can reduce patients’ international normalized ratio very rapidly and with less fluid infusion vs fresh frozen plasma, but these newer therapies are associated with a higher risk for thromboembolism.
• The decision of whether to reinitiate warfarin therapy following ICH should be individualized based on the patient’s risk for repeat ICH and thromboembolism. Warfarin may be restarted 7 to 10 days following ICH among patients at high risk for thromboembolism.
• Surgical intervention should be considered for patients with cerebellar hemorrhage of 3 cm or greater who are deteriorating neurologically. Patients with brainstem compression or ventricular obstruction resulting from hemorrhage may also be considered for surgical intervention. Patients with lobar clots within 1 cm of the surface may be considered for evacuation of ICH with craniotomy.

Pearls for Practice

• ICH accounts for up to 15% of first-time strokes and associated mortality rates can exceed 50%. Half of patients with ICH who die do so in the first 2 days following hemorrhage.
• The current guidelines for patients with ICH recommend initial conservative measures to reduce ICP and prophylaxis against deep venous thrombosis for all ICH patients with limited mobility. Warfarin therapy may be restarted among patients with ICH who are at high risk for thromboembolism.

News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD

“Syncope is a symptom complex that is composed of a brief loss of consciousness associated with an inability to maintain postural tone that spontaneously and completely resolves without medical intervention,” write ACEP Subcommittee Chair J. Stephen Huff, MD, and colleagues. “It is distinct from vertigo, seizures, coma, and states of altered consciousness. Syncope is a common presentation to the emergency department (ED) that accounts for 1% to 1.5% of ED annual visits and up to 6% of hospital admissions.”

Difficulties encountered in the ED evaluation of patients with syncope may include missing, inaccurate, or conflicting historical information from observers; lack of memory for the event when patients arrive in the ED; and often asymptomatic state by the time patients reach the hospital.

Causes of syncope include any process that transiently reduces cerebral perfusion.

“Concerns that well-appearing patients are at risk for sudden death often fuel extensive clinical evaluations or hospital admissions because the large differential diagnosis includes some processes that may be life-threatening,” the authors write. “Many studies have demonstrated the low yield of nondirected diagnostic testing. From the available literature, it is unclear whether admitting asymptomatic syncope patients for observation and inpatient evaluation affects patient outcome.”

Costs of hospitalization of patients with syncope are estimated at more than $2 billion annually in the United States. The authors note that applying the level B recommendations of the 2001 ACEP clinical policy on syncope would identify all patients with cardiac causes of syncope and reduce the admission rate from 57.5% to 28.5%.

These facts prompted the ACEP Subcommittee to reevaluate the role of the emergency clinician when treating the patient presenting with syncope. Those relatively few patients with life-threatening processes (including dysrhythmias, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, acute coronary syndromes), and other patients who may benefit from urgent intervention (such as patients with bradycardia or medication-induced orthostatic hypotension), must still be identified.

When the ED evaluation of a patient presenting with syncope does not identify a clear etiology, the emergency clinician must then determine which of these patients need additional diagnostic evaluation and monitoring, and in what setting that should take place. Similar to the process of chest pain evaluation, the role of the ED clinician managing syncope has shifted from an effort to determine a specific diagnosis to that of risk stratification.

Symptoms and complaints of the patient with syncope should be carefully considered after performing a complete history. Other associated symptoms (eg, cardiac, neurologic, abdominal, or respiratory) may facilitate diagnosis of an underlying medical condition, such as an acute coronary event, aortic dissection, pulmonary embolism, seizure, ectopic pregnancy, or gastrointestinal hemorrhage.

The current update of the 2001 ACEP clinical policy on syncope does not attempt to outline the evaluation of patients presenting with syncope associated with specific diagnoses, but instead attempts to assist the ED clinician with 3 critical issues:

1. What history and physical examination data help to risk-stratify patients with syncope?
   • Level A recommendations: History or physical findings consistent with heart failure may help identify patients at higher risk for an adverse outcome.
   • Level B recommendations: Older age, structural heart disease, or a history of coronary artery disease are risk factors for adverse outcomes. Younger patients with nonexertional syncope and patients without history or signs of cardiovascular disease, a family history of sudden death, and comorbidities are at low risk for adverse events.
   • Level C recommendations: None specified.
2. What diagnostic testing data help to risk-stratify patients with syncope?
   • Level A recommendations: Patients with syncope should undergo a standard 12-lead electrocardiogram (ECG).
   • Level B recommendations: None specified.
   • Level C recommendations: echocardiography, cranial computed tomographic (CT) scanning, and other laboratory testing and advanced investigative testing should not be performed routinely in the absence of specific findings in the history or physical examination.
3. Who should be admitted to the hospital after an episode of syncope of unclear cause?
   • Level A recommendations: None specified.
   • Level B recommendations: Patients with syncope and evidence of heart failure or structural heart disease should be admitted to the hospital, as should patients with syncope and other factors that lead to stratification as high-risk for adverse outcome (older age and associated comorbidities; ECG abnormalities, including acute ischemia, dysrhythmias, or significant conduction abnormalities; hematocrit value less than 30; and history or presence of heart failure, coronary artery disease, or structural heart disease).
   • Level C recommendations: None specified.

“A small number of studies have explored a clinical decision or observation unit, with testing or consultation as an alternative to inpatient admission in patients stratified as neither high-risk nor low-risk for adverse outcomes (ie, intermediate-risk patients),” the authors conclude. “Further studies are needed to identify distinct subgroups that might benefit from this strategy. The distinction between ED evaluation and admission is blurring with the availability of additional diagnostic resources, the opportunity for longer observation periods, and the reality of prolonged ED stays.”

The Emergency Nurses Association supported this study.

Ann Emerg Med. 2007;49:431-444.add student consolidation loanar cash advance loanflexible adverse loanaffordable housing loanprogram alaska student loansloan center residential americaday loan pay $5001000 loans guaranteed Map