美国自发性脑出血指南Word文件下载.docx

1、3. Craig S. Anderson, MD, PhD;4. Kyra Becker, MD, FAHA;5. Bernard R. Bendok, MD, MS, FAHA;6. Mary Cushman, MD, MSc, FAHA;7. Gordon L. Fung, MD, MPH, PhD, FAHA;8. Joshua N. Goldstein, MD, PhD, FAHA;9. R. Loch Macdonald, MD, PhD, FRCS;10. Pamela H. Mitchell, RN, PhD, FAHA;11. Phillip A. Scott, MD, FAH

2、A;12. Magdy H. Selim, MD, PhD;13. Daniel Woo, MD, MS;14. on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Clinical Cardiology Next SectionAbstractPurposeThe aim of this guideline is to present current and comprehensive recommend

3、ations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. MethodsA formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Hea

4、rt Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and St

5、roke Council Leadership Committee. ResultsEvidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the

6、role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. ConclusionsIntracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework fo

7、r goal-directed treatment of the patient with intracerebral hemorrhage. Key Words: AHA Scientific Statements blood pressure coagulopathy diagnosis intracerebral hemorrhage intraventricular hemorrhage surgery treatmentPrevious SectionNext SectionIntroductionSpontaneous, nontraumatic intracerebral hem

8、orrhage （ICH） remains a significant cause of morbidity and mortality throughout the world. Although ICH has traditionally lagged behind ischemic stroke and aneurysmal subarachnoid hemorrhage in terms of evidence from clinical trials to guide management, the past decade has seen a dramatic increase i

9、n studies of ICH intervention. Population-based studies show that most patients present with small ICHs that are readily survivable with good medical care.1 This suggests that excellent medical care likely has a potent, direct impact on ICH morbidity and mortality. This guideline serves several purp

10、oses. One is to provide an update to the last American Heart Association/American Stroke Association ICH guideline, published in 2010, incorporating the results of new studies published in the interim.2 Another equally important purpose is to remind clinicians of the importance of their care in dete

11、rmining ICH outcome and to provide an evidence-based framework for that care. To make this review brief and readily useful to practicing clinicians, background details of ICH epidemiology are limited, with references provided for readers seeking more details.1,3,4 Ongoing studies are not discussed s

12、ubstantively because the focus of this guideline is on currently available therapies; however, the increase in clinical studies related to ICH is encouraging, and those interested may go to http:/www.strokecenter.org/trials/ for more information. Also, this guideline is generally concerned with adul

13、ts, with issues of hemorrhagic stroke in children and neonates covered in a separate American Heart Association scientific statement on “Management of Stroke in Infants and Children.”5This document serves to update the last ICH guidelines published in 2010,2 and the reader is referred to these guide

14、lines for additional relevant references not contained here. The development of this update was purposely delayed for 1 year from the intended 3-year review cycle so that results of 2 pivotal phase 3 ICH clinical trials could be incorporated. Differences from recommendations in the 2010 guideline ar

15、e specified in the current work. The writing group met by phone to determine subcategories to evaluate. These included 15 sections that covered the following: emergency diagnosis and assessment of ICH and its causes; hemostasis and coagulopathy; blood pressure （BP） management; inpatient management,

16、including general monitoring and nursing care, glucose/temperature/seizure management, and other medical complications; procedures, including management of intracranial pressure （ICP）, intraventricular hemorrhage, and the role of surgical clot removal; outcome prediction; prevention of recurrent ICH

17、; rehabilitation; and future considerations. Each subcategory was led by a primary author, with 1 or 2 additional authors making contributions. Full PubMed searches were conducted of all English language articles regarding relevant human disease treatment from 2009 through August 2013. Drafts of sum

18、maries and recommendations were circulated to the entire writing group for feedback. Several conference calls were held to discuss individual sections, focusing on controversial issues. Sections were revised and merged by the Chair. The resulting draft was sent to the entire writing group for commen

19、t. Comments were incorporated by the Chair and Vice-Chair, and the entire committee was asked to approve the final draft. Changes to the document were made by the Chair and Vice-Chair in response to peer review, and the document was again sent to the entire writing group for suggested changes and ap

20、proval. Recommendations follow the American Heart Association/American Stroke Associations methods of classifying the level of certainty of the treatment effect and the class of evidence （Tables 1 and 2）. All Class I recommendations are listed in Table 3. View this table: In this window In a new win

21、dowTable 1. Applying Classification of Recommendations and Level of EvidenceTable 2. Definition of Classes and Levels of Evidence Used in AHA/ASA RecommendationsTable 3. Class I RecommendationsEmergency Diagnosis and AssessmentICH is a medical emergency. Rapid diagnosis and attentive management of p

22、atients with ICH is crucial, because early deterioration is common in the first few hours after ICH onset. More than 20% of patients will experience a decrease in the Glasgow Coma Scale （GCS） of 2 or more points between the prehospital emergency medical services （EMS） assessment and the initial eval

23、uation in the emergency department （ED）.6 Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital arrival.7,8 The risk for early neurological deterioration and the high rate of poor long-term outcomes underscore the need for aggressive ea

24、rly management. Prehospital ManagementPrehospital management for ICH is similar to that for ischemic stroke, as detailed in the recent American Heart Association “Guidelines for the Early Management of Patients With Acute Ischemic Stroke.”9 The primary objective is to provide airway management if ne

25、eded, provide cardiovascular support, and transport the patient to the closest facility prepared to care for patients with acute stroke.10 Secondary priorities for EMS providers include obtaining a focused history regarding the timing of symptom onset （or the time the patient was last normal）; infor

26、mation about medical history, medication, and drug use; and contact information for family. EMS providers should provide advance notice to the ED of the impending arrival of a potential stroke patient so that critical pathways can be initiated and consulting services alerted. Advance notice by EMS h

27、as been demonstrated to significantly shorten time to computed tomography （CT） scanning in the ED.11 Two studies have shown that prehospital CT scanning with an appropriately equipped ambulance is feasible and may allow for triage to an appropriate hospital and initiation of ICH-specific therapy.12,

28、13ED ManagementEvery ED should be prepared to treat patients with ICH or have a plan for rapid transfer to a tertiary care center. The crucial resources necessary to manage patients with ICH include neurology, neuroradiology, neurosurgery, and critical care facilities that include adequately trained

29、 nurses and physicians. Consultants should be contacted as quickly as possible while the patient is in the ED, and the clinical evaluation should be performed efficiently, with physicians and nurses working in parallel. Consultation via telemedicine can be a valuable tool for hospitals without on-si

30、te presence of consultants.14,15 Table 4 describes the integral components of the history, physical examination, and diagnostic studies that should be obtained in the ED. Table 4. Integral Components of the History, Physical Examination, and Workup of the Patient With ICH in the Emergency Department

31、A routine part of the evaluation should include a standardized severity score, because such scales can help streamline assessment and communication between providers. The National Institutes of Health Stroke Scale （NIHSS） score, commonly used for ischemic stroke, may also be useful in ICH.24,25 However, ICH patients more often have depressed consciousness on initial