1. The ED Management of Pediatric Intracerebral Hemorrhage Patients Edward P. Sloan, MD, MPH, FACEP

2. Edward Sloan, MD, MPH Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL Edward P. Sloan, MD, MPH, FACEP

3. Attending Physician Emergency Medicine Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL Edward P. Sloan, MD, MPH, FACEP

4. Global Objectives Improve outcome in pediatric stroke & ICH Know how to Rx pediatric ICH patients Understand current guidelines Be aware of future therapies Improve Emergency Medicine practice

5. Edward P. Sloan, MD, MPH, FACEP Session Objectives Review peds stroke epidemiology, etiology Examine adult ICH patient ED Rx Discuss the relevant treatment issues Explore pediatric ICH ED Rx Discuss NIHSS & ED documentation Consider articles that might change EM practice both in adults and children

6. Edward P. Sloan, MD, MPH, FACEP Pediatric Stroke and ICH: Epidemiology, Etiology and ED Presentation

7. Edward P. Sloan, MD, MPH, FACEP Pediatric Stroke Epidemiology Children to age 19: –Incidence rate: 2.3/100,000 –1.2 ischemic, 1.1 hemorrhagic (ICH 2x > SAH) –Greatest risk up to one year of age Young adults age 20-45: –Incidence rate: 23/100,000 –10 ischemic, 13 hemorrhagic Males, minorities at greater risk

8. Edward P. Sloan, MD, MPH, FACEP Pediatric Stroke Etiology Hemorrhagic strokes: AVMs, arterial aneurysms, stimulants and hematological conditions Ischemic strokes: hematological (sickle cell disease), vasculitides, metabolic and genetic conditions Al-Jarallah: ICH, 68 non-trauma pediatric pts: –Over 90% had some risk factor for ICH –43% with a congenital vascular abnormality –32% with a coagulation disorder –13% with a CNS tumor.

9. Edward P. Sloan, MD, MPH, FACEP Pediatric Stroke Outcomes Recent overall in-hospital mortality: 16.5% Mortality: SAH 75%, ICH 54%, ischemic 19% Blacks, males higher mortality risk Greatest risk seen in age < one year pts Mortality rate down by 58% over 20 years ICH: 50% have residual impairment Quality of life diminished in hemophilia, ICH

10. Edward P. Sloan, MD, MPH, FACEP Pediatric Stroke ED Presentation 68 ICH pediatric patients –Headache and vomiting in 59% –Seizures in 37% –Hemiparesis in 16% –Irritability in 9% –Coma in only 3% of patients Al-Jarallah A, J Child Neurol, 2000

11. Edward P. Sloan, MD, MPH, FACEP Stroke Type Prediction 540 adult patients, 18% hemorrhagic Hemorrhagic stroke: onset during physical activity, headache onset within 2 hours, AMS, meningismus, increased SBP Ischemia stroke: history of obesity, peripheral arterial disease, TIA history, and the presence of hemiparesis Model 99% accurate in excluding ICH Sturmer T, Neuroepidemiology, 2002

12. Edward P. Sloan, MD, MPH, FACEP Intracerebral Hemorrhage: Pathophysiology

13. Edward P. Sloan, MD, MPH, FACEP

14. ICH Volume and Outcome Broderick: 1993 Stroke Key Concept: Hemorrhage volume and GCS predict 30 day mortality Data: 60 cc blood, GCS < 9, mort 91% Data: 30 cc blood, GCS > 8, mort 19% Implications: Simple ED observations allow for a reasonable outcome assessment

15. Edward P. Sloan, MD, MPH, FACEP ICH Volume and Outcome Broderick: 1993 Stroke Data: 3 volumes, 2 GCS strata Data: 96% sensitivity, 98% specificity Data: 30+cc bleed, 1/71 independ at 30 d Implications: EM physicians can know likely outcome, allowing for realistic discussions with family & neurosurgeon

16. Edward P. Sloan, MD, MPH, FACEP

17. ICH Hemorrhage Growth Brott: 1997 Stroke Key Concept: ICH volume is dynamic, changes correlate clinically Data: 1 hr: 26% had 1/3 growth Data: 20 hr: another 12% had 33% growth Data: 1/3 growth = drop in NIHSS, GCS Implications: Efforts directed at stabilizing hemorrhage volume may impact patient outcome

18. Edward P. Sloan, MD, MPH, FACEP The ED Management of Intracerebral Hemorrhage

19. Edward P. Sloan, MD, MPH, FACEP

20. ICH Treatment Guidelines ASA Council: 1999 Stroke Key Concept: ICH guidelines exist Data: Detailed data on disease, epi Data: Specific recs on BP, ICP Rx Implications: This article will enhance the understanding of any EM physician on acute ICH patient management, make care consistent

21. Edward P. Sloan, MD, MPH, FACEP ICH Overview Emesis, AMS, HTN CT is the test of choice Angiography if surgery is indicated No angiography if surgery not clinically indicated or if no likely surgical lesion Timing of angiography can be variable

22. Edward P. Sloan, MD, MPH, FACEP ICH & MRI MRI and MRA may replace angiography Indications becoming better known Example: If angiography negative, but surgery is still a consideration Type, location of bleed may also suggest surgical lesion and desire to further test with MRI, MRA

23. Edward P. Sloan, MD, MPH, FACEP ICH & BP Management Remember: only 4 studies on acute Rx! Be aggressive, treat elevated BP Caveat: No clear relationship between BP Rx and hemorrhage volume, outcome More recent data may more clearly show benefits of aggressive BP Rx

24. Edward P. Sloan, MD, MPH, FACEP ICH & BP Management 230/140: go directly to nitroprusside Marked elevations: labetalol, esmolol, analapril or other titratable medications Maintaining MAP at an elevated level key Normal MAP in older HTN pt may be 110 230/140: MAP of 170 May wish to treat to MAP of 120-130

25. Edward P. Sloan, MD, MPH, FACEP ICH & ICP Management Elevated ICP: > 20 mm HG CPP = MAP – ICP (110- 10 = 100 mm Hg) Need to maintain CPP > 70 mm Hg If SBP 20, CPP less than 70 Fluids boluses to maintain adequate BP Careful SBP Rx if the pt is hypertensive

26. Edward P. Sloan, MD, MPH, FACEP ICH & ICP Management Head of bed elevation Mannitol: 0.5 g/kg every four hours Steroids: Not clinically indicated pCO2: 30-35, constant TV 12-14 ml/kg Adjust pCO2 by changing RR on vent In TBI, only useful with pt deterioration Benzos, paralysis to avoid ICP spikes Euvolemia; Avoid fever, seizures

27. Edward P. Sloan, MD, MPH, FACEP ICH: Surgical Concepts Remember: Only 4 clinical trials! Total of 353 patients studied in all Remove clot, reduce pressure Manage brain trauma and edema Minimize trauma (superficial clots best) Minimally invasive approaches now used 75-100% mortality in surgical ICH trials

28. Edward P. Sloan, MD, MPH, FACEP ICH: Surgical Indications Hard to specify…however… Cerebellar hemorrhage: 3 cm or larger or those that cause mass effect, compression ICH related to a surgical lesion Young patients who deteriorate Other indications less clear

29. Edward P. Sloan, MD, MPH, FACEP

30. STITCH ICH Surgical Trial Mendelow: 2005 Lancet Key Concept: Surgery within 24 hours does not affect 6 month outcome Data: 25% of pts had a good outcome Data: Surgery did not change this rate Implications: ED Rx becomes more important, given lower likelihood of operative neurosurgical intervention

31. Edward P. Sloan, MD, MPH, FACEP STITCH ICH Surgical Trial Mendelow: 2005 Lancet 1033 pts, non-US settings Data: early surgery vs. medical, surgical Data: Hemorrhage volume: 40 cc Data: 81% had GCS 9-15 Data: Surgical time: 30 hrs, 60 hrs Data: Only 16% had surgery < 12 hrs

32. Edward P. Sloan, MD, MPH, FACEP STITCH ICH Surgical Trial Mendelow: 2005 Lancet Key concept: This study may not exactly tell the story of US practice May still need to consider operative intervention, will need to stabilize patients first

33. Edward P. Sloan, MD, MPH, FACEP The ED Management of Intracerebral Hemorrhage: Implications in Peds Patients

34. Edward P. Sloan, MD, MPH, FACEP Calder K: ED Pediatric Stroke

35. Edward P. Sloan, MD, MPH, FACEP Cardiopulmonary, Physiologic Maintain adequate oxygenation Hypotension rare: Rx fluids, pressors Treat hyperthermia Treat hyper and hypoglycemia Prophylaxis, Rx seizures in ICH Nimodipine in SAH Reverse coagulopathies tPA not studied in children

36. Edward P. Sloan, MD, MPH, FACEP Antihypertensive Rx Hypertension rare etiology of peds stroke Rx elevated BP as in adults, titratable Rx Rx BP aggressively with aortic dissection and in setting of encephalopathy

37. Edward P. Sloan, MD, MPH, FACEP Elevated ICP Rx Bolus mannitol in setting of neurological deterioration presumed due to ICP Also Rx with mild hyperventilation pCO2 30-35 mm Hg when neurological deterioration observed and ICP implicated Prophylaxis with these Rx NOT indicated Caution: hyperosmolarity, renal failure

38. Edward P. Sloan, MD, MPH, FACEP NIHSS & ED Pediatric Stroke Patient Documentation

39. Edward P. Sloan, MD, MPH, FACEP Four Main NIHSS Areas CN/Visual:Facial palsy, gaze palsy, visual field deficit Unilateral motor:Hemiparesis LOC: Depressed LOC, poor responsiveness Language:Aphasia, dysarthria, neglect 28 total points

40. Edward P. Sloan, MD, MPH, FACEP NIHSS ED Estimate CN (visual):8 Unilateral motor:8 LOC: 8 Language/Neglect:8 Mild: 2, Moderate: 4, Severe: 8 +/- Incorporates other elements

41. Edward P. Sloan, MD, MPH, FACEP Case NIHSS Estimate CN/Visual: R vision loss, no fixed gaze4 Unilateral motor: hemiparesis8 LOC: mild decreased LOC2 Language:speech def, neglect4 Approx 18 points total Severe stroke range, worse if MS impaired

42. Edward P. Sloan, MD, MPH, FACEP Patient Neuro Exam CN: R mouth droop, no lid weakness Motor: R upper and lower ext weakness Sensory: ?? Light touch dec R Reflex: No pathological relexes Normal corneals Normal gag reflex

43. Edward P. Sloan, MD, MPH, FACEP Patient Neuro Exam Cerebellar: Slight truncal ataxia, to R Visual/Neglect: ?? Lost vision & neglect, R Language: Dysarthria, expressive aphasia No receptive aphasia LOC: Slightly somnolent, responds to verbal stimuli, GCS=14 Approximate NIHSS: 8

44. Edward P. Sloan, MD, MPH, FACEP CT Documentation ICH: L parietal area 5 cm diameter No skull fracture evident No subdural or epidural No mass effect or midline shift No ventricular extension No hydrocephalus

45. Edward P. Sloan, MD, MPH, FACEP ICH Patient Management Airway patent, urgent intubation NCI CT findings: parietal ICH, no SAH HTN noted. Labetalol Rx to MAP= 120 No deterioration or acute ICP Rx Fosphenytoin given Pt stable, critical family aware Neurosurgery to evaluate pt, CT Surgical Rx prn

46. Edward P. Sloan, MD, MPH, FACEP Diagnoses AMS, near syncope Intracerebral Hemorrhage HTN Critical care time 35 minutes

47. Edward P. Sloan, MD, MPH, FACEP ED Pediatric ICH Patients: Journal Club

48. Edward P. Sloan, MD, MPH, FACEP

49. FVIIa in Warfarin-Related ICH Freeman: 2004 Mayo Clin Proc Key Concept: Warfarin-related ICH can be treated successfully with rec FVIIa Data: 62 micrograms/kg Factor VIIa Data: INR decreased from 2.7 to 1.1 Implications: This therapy used today as an adjunct to blood therapies in ICH patients whose bleed is INR-related

50. Edward P. Sloan, MD, MPH, FACEP FVIIa in Warfarin-Related ICH Freeman: 2004 Mayo Clin Proc Data: 12-28% growth by 24 hours Data: INR normalized within 2 hours Implications: May facilitate craniotomy for patients who are surgical candidates

51. Edward P. Sloan, MD, MPH, FACEP

52. Rec FVIIa Safety in ICH Mayer: 2005 Stroke Key Concept: FVIIa is safe when given within 3 hours of presentation Data: 36 patients, 6 doses tested Data: No safety issues preclude phase III Implications: Larger study is justified, given data on hemorrhage volume growth and outcome

53. Edward P. Sloan, MD, MPH, FACEP Rec FVIIa Safety in ICH Mayer: 2005 Stroke Key Concept: Careful with thromboembolic events Data: 2 Significant AEs Data: DVT at 72 hours, Angina at 29 days Implications: Careful pt selection may allow for minimal complications to occur

54. Edward P. Sloan, MD, MPH, FACEP

55. FVIIa Safety, Efficacy in ICH Mayer: 2005 NEJM Key Concept: FVIIa is safe when given within 3 hours of presentation Data: 399 pts, 3 doses, ICH growth, 90-day Data: Less ICH growth, improved outcome Data: Thromboembolic events noted Implications: Larger study is critical in order to establish clear benefit, safety

56. Edward P. Sloan, MD, MPH, FACEP FVIIa Safety, Efficacy in ICH Mayer: 2005 NEJM Key Concept: Optimal patient population Data: GCS 14, NIHSS 12-15 Data: 24 cc hemorrhage volume Data: 180 minutes to treatment Implications: Good population for surgical Rx, fits with ED paradigm of stabilization Role in larger population of ICH pts?

57. Edward P. Sloan, MD, MPH, FACEP FVIIa Safety, Efficacy in ICH Mayer: 2005 NEJM Key Concept: Good outcome, limited AEs Data: 47 vs. 31 % favorable outcome Data: NIHSS 6 vs. 12 Data: 7 cardiac ischemia, 9 CVAs, 1 AMI Implications: May represent a favorable risk/benefit profile

58. Edward P. Sloan, MD, MPH, FACEP

59. FVIIa in ICH: Commentary Brown: 2005 NEJM Key Concept: Editorial provides perspective on Mayer study Data: How should data be interpreted? Data: What can be learned from study? Implications: What are the implications of this study? What do we do now?

60. Edward P. Sloan, MD, MPH, FACEP FVIIa in ICH: Commentary Brown: 2005 NEJM Key Concept: Many unknowns persist Data: BP and ICH management unclear Data: Surgical Rx indications variable Implications: Use it for good surgical candidate, related to elevated INR, in pt not at high risk for thromboembolic event

61. Edward P. Sloan, MD, MPH, FACEP

62. NINDS ICH Research Agenda NINDS Workshop: 2005 Stroke Key Concept: Fundamental questions Re: ICH treatment and research Data: Critical medical, surgical issues Data: Extensive info regarding acute Rx Implications: Although much theoretical info, an important source of facts that will enhance current clinical practice

63. Edward P. Sloan, MD, MPH, FACEP NINDS ICH Research Agenda NINDS Workshop: 2005 Stroke Key Concept: Landmark article Data: 6 writing groups Data: 226 references Implications: A must for any educator or clinician who wishes to know more about the optimal ED Rx of ICH patients

64. Edward P. Sloan, MD, MPH, FACEP Key Learning Points ICH is a dynamic process, volume key Outcome related to volume, mental status Guidelines exist that drive clinical practice Pediatric ED Rx derived from adult Rx Future research with FVIIa critical Research priorities based on clinical need Pt outcome and EM practice can be enhanced in adults & children

65. Questions?? www.ferne.org ferne@ferne.org Edward P. Sloan, MD, MPH 312 413 7490 Questions?? www.ferne.org ferne@ferne.org Edward P. Sloan, MD, MPH edsloan@uic.edu 312 413 7490 www.ferne.org ferne_acep_2005_peds_sloan_ich_edrx_fshow.ppt 8/6/2015 9:53 AM Edward P. Sloan, MD, MPH, FACEP