Rosen & Barkin's 5-Minute Emergency Medicine Consult (397 page)

• C-spine precautions if head or neck injury is suspected
  
• Elevation of head with C-spine control
  
• Initial pre-hospital responder must ascertain neurologic defect to be able to note progression of symptoms
  

• Manage airway and resuscitate as needed:
  
  • Patients with depressed level of consciousness should be intubated immediately for controlled ventilation
    
• Early neurosurgical consultation
  

• Prompt neurosurgery and/or neurology consultation
  
• BP management:
  
  • Must use caution in BP control because acute lowering of BP to normal in setting of increased ICP could reduce cerebral perfusion to ischemic levels
    
  • Use labetalol, nicardipine, esmolol, enalapril to lower diastolic BP initially by 10%
    
  • Normotensive levels should be achieved over 12–24 hr
    
  • May use nitroprusside, nitroglycerin, or hydralazine as an alternative
    
• Treatment of elevated ICP:
  
  • Controlled ventilation to PaCO
    ₂
    of 35 Torr
    
  • Fluid restriction; elevate head of bed 30°
    
  • Mannitol—osmotic diuresis
    
  • Use furosemide as an alternative
    
• Correct coagulopathies:
  
  • Consider fresh frozen plasma (FFP), platelets, prothrombin complex concentrates, vitamin K
    
• Consider anticonvulsants
  
  • Phenytoin, fosphenytoin
    

• Esmolol: 0.5–1 mg/kg initial bolus IV, followed by 50–150 μg/kg/min infusion
  
• Enalapril: 1.25–5 mg q6h (risk of precipitous BP lowering, test dose 0.625 mg)
  
• FFP: 10–20 mL/kg IV
  
• Fosphenytoin: 15–20 mg/kg phenytoin equivalents (PE) at rate of 100–150 mg/min IV/IM
  
• Furosemide: 20–40 mg (peds: 0.5–1 mg/kg/dose) IV; may repeat as necessary
  
• Hydralazine: 10–40 mg (peds: 0.1–0.2 mg/kg/dose; max. 20 mg/dose) IV; may repeat as necessary
  
• Labetalol: 20 mg (peds: 0.3–1 mg/kg/dose; max. 20 mg/dose) IV; may give additional 40–80 mg IV q10min to max. 300 mg
  
• Mannitol: 1 g/kg IV
  
• Nicardipine: 5–15 mg/h infusion
  
• Nitroprusside: Start 0.25–10 μg/kg/min IV (max. 10 μg/kg/min); titrate to effect
  
• Phenytoin: 15–20 mg/kg/dose (peds: 15 mg/kg) at rate of <40–50 mg/min
  
• Platelet: 1–2 U IV in consultation with neurosurgery
  
• Prothrombin complex concentrates: 500–1,000 IU IV
  
• Vitamin K: 5–10mg IV over 30 min
  

FOLLOW-UP

• To OR if surgical intervention is indicated
  
• To ICU if intubated, altered level of consciousness, or on IV infusion for BP control
  
• Admit to neurologic observation unit if normal neurologic exam without evidence of progression of bleed and hemodynamically stable
  

All patients with intracerebral hemorrhage should be admitted

Rehabilitation is a key aspect of recovery

• Treating HTN in the nonacute setting is the most important step to reduce the risk of intracerebral hemorrhage
  
• Discontinuation of smoking, alcohol use, and cocaine use prevents recurrence of intracerebral hemorrhage
  

• Brain imagining is a crucial part of emergent evaluation of patients with headache, HTN, and/or altered level of consciousness
  
• Cautious BP control because acute lowering of BP to normal in setting of ICP could reduce cerebral perfusion to ischemic levels
  
• Consider delayed intracranial bleed in patients on anticoagulation with head trauma
  

• Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: A guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group.
  Stroke
  . 2007;38:2001–2023.
  
• Caceres JA, Goldstein JN. Intracranial hemorrhage.
  Emerg Med Clin North Am
  . 2012;30:771–794.
  
• Naval NS, Nyguist PA, Carhuapoma JR. Management of spontaneous intracerebral hemorrhage.
  Neurol Clin
  . 2008;26:373–384.
  
• Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.
  Ann Emerg Med
  . 2012;59:460–468.
  
• Nishijima DK, Offerman SR, Ballard DW, et al. Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use.
  Acad Emerg Med.
  2013;20:140–145.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Headache
  
• Hypertensive Emergencies
  
• Seizure
  

CODES

• 431 Intracerebral hemorrhage
  
• 853.00 Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness
  

BASICS

• The proximal bowel invaginates into the distal bowel, producing infarction and gangrene of the inner bowel:
  
  • >80% involve the ileocecal region.
    
• Often occurs with a pathologic lead point in children >2 yr:
  
  • Hypertrophied lymphoid patches may be present in infants.
    
  • Children >2 yr: 1/3 of patients have pathologic lead point.
    
  • Children >6 yr: Lymphoma is the most common lead point.
    
  • Adults usually have a pathologic lead point.
    
• The most common cause of intestinal obstruction within the 1st 2 yr of life
  
• Epidemiology in US:
  
  • Most frequently between 5 and 9 mo of age
    
  • Incidence is 2.4 cases per 1,000 live births.
    
  • Male > female predominance of 2:1
    
  • Mortality <1%
    
• Morbidity increases with delayed diagnosis.
  

• Most cases (85%) have no apparent underlying pathology.
  
• Predisposing conditions that create a lead point for invagination, esp. in older children and adults:
  
  • Masses/tumors:
    
    • Lymphoma
      
    • Lipoma
      
    • Polyp
      
    • Hypertrophied lymphoid patches
      
    • Meckel diverticulum
      
  • Infection:
    
    • Adenovirus or rotavirus infection
      
    • Parasites
      
  • Foreign body
    
  • Henoch–Schönlein purpura
    
  • Celiac disease and cystic fibrosis (small intestine intussusception)
    

DIAGNOSIS

• Classic triad (present in <50% of patients):
  
  • Abdominal pain
    
  • Vomiting, often bilious
    
  • Stools have blood and mucus (“currant jelly” stools)
    
• Recurrent painful episodes accompanied by pallor and drawing up of the legs; intermittent fits of sudden intense pain with screaming and flexion of legs:
  
  • Occur in 5–20 min intervals
    
• Mental status changes:
  
  • Irritability
    
  • Lethargy or listlessness; child can be limp or have a rag doll appearance.
    
  • May precede abdominal findings.
    
• Stool variable:
  
  • Heme-positive (occult), bloody, or “currant jelly”
    
• Preceding illness several days or weeks prior to the onset of abdominal pain:
  
  • Diarrhea
    
  • Viral syndrome
    
  • Henoch–Schönlein purpura
    
• Recurrent intussusception occurs in <10% of patients.