How to treat acute cerebral hemorrhage? Detailed explanation of emergency, medical, and surgical treatment plans.

Treatment of Cerebral Hemorrhage:

Cerebral hemorrhage is more common in patients over 50 years of age. Approximately 80% occur in the cerebral hemispheres, primarily in the basal ganglia, with the remaining 20% ​​occurring in the brainstem and cerebellum.

(I) Acute Phase Treatment Several hours or days before onset, patients may experience headache, dizziness, vomiting, mental disturbances, and blurred vision. Hemorrhage often occurs during the day, when the patient is emotionally agitated, exerts excessive force, is under mental stress, or while resting or sleeping. It is more common in cold seasons. Cerebral hemorrhage has a rapid onset and progression. Typical symptoms include: severe headache, vomiting, hemiplegia, aphasia, altered consciousness, coma, fever, slow and deep breathing, and elevated blood pressure; if the hematoma enters the ventricles, symptoms such as high fever and urinary and fecal incontinence may occur.

1. First Aid The principle of first aid is to stop further bleeding and prevent complications. Note that morphine should not be used during first aid as it suppresses the respiratory center.

(1) Absolute bed rest, head elevated approximately 30 degrees, and kept quiet. (1) Avoid unnecessary movement and closely monitor changes in consciousness, pupils, and vital signs.

(2) Maintain a clear airway. Clear airway secretions promptly; administer oxygen or perform cardiopulmonary resuscitation for those experiencing difficulty breathing. Antibiotics may be used if infection is present.

(3) Control hypertension. If blood pressure is too high, administer 1 mg of dextromethorphan intramuscularly, or 10 ml of 25% magnesium sulfate, or 10 mg of nifedipine sublingually.

(4) Perform local physical cooling of the head. Apply ice caps or ice packs to the head and neck to lower brain temperature, which helps reduce cerebral edema and intracranial pressure.

(5) Reduce cerebral edema by administering appropriate dehydrating agents such as 250 ml of 20% mannitol intravenously over 30 minutes, or 1–1.5 g/kg of 25% sorbitol, and add 10 mg/day of dexamethasone intravenously. Limit daily fluid intake to 1500–2000 ml. (6) For patients with coagulation disorders, 4-6g of 6-aminocaproic acid or 100-200mg of antifibrinolytic acid can be administered intravenously twice daily.

(7) Fasting should begin for 1-2 days, with approximately 2000ml of fluid supplementation daily during this period. After 2-3 days, milk can be fed via nasogastric tube in small, frequent doses, gradually increasing the amount.

2. Medical Treatment

(1) General Treatment
① Quiet bed rest with the head of the bed elevated to maintain a clear airway. Regular turning and back bending are necessary to prevent pneumonia and bedsores.

② For restless or epileptic patients, sedatives, antispasmodics, and analgesics should be administered.

③ Head cooling should be achieved using ice caps or ice water to lower brain temperature and reduce intracranial metabolism, which helps alleviate cerebral edema and intracranial hypertension. (2) Adjusting Blood Pressure
For those with elevated blood pressure, 1 mg of reserpine can be injected intramuscularly. This can be repeated if necessary. If the patient is conscious or receiving nasogastric feeding, 1-2 tablets of compound antihypertensive tablets can be taken orally, 2-3 times daily, maintaining blood pressure around 20.0-21.3/12.0-13.3 kPa. If blood pressure is too low, the cause (such as acidosis, dehydration, gastrointestinal bleeding, cardiogenic or septic shock, etc.) should be identified and corrected promptly. Dopamine, Aramine, or other vasopressors should be used to raise blood pressure in a timely manner. Fresh blood transfusions may be necessary, but blood pressure should not be lowered too quickly or excessively in a short period to avoid affecting cerebral blood circulation.

(3) Reducing Intracranial Pressure

① Dehydrating agents: 250 ml of 20% mannitol or 25% sorbitol should be administered intravenously over 30 minutes, once every 6-8 hours depending on the patient's condition, for 7-15 days as one course of treatment. ② Diuretics: Furosemide 40-60mg dissolved in 20-40ml of 50% glucose solution, intravenously; sodium ethacrylate 25mg can also be administered intravenously; every 6-8 hours, preferably alternated with dehydrating agents on the same day to prevent rebound effect after discontinuation of dehydrating agents, which could cause a resurgence of intracranial pressure.

③ Alternatively, 10% glycerol solution 250-500ml can be administered intravenously, 1-2 times/day, for 5-10 days as one course of treatment.

④ Hormones: Hormones should be used judiciously, weighing the benefits and risks, and are best used for short periods during the acute phase. Dexamethasone is the first-line drug, with a daily dose of 20-60mg, divided into 2-4 intravenous injections. Dexamethasone has minimal effect on sodium and water retention, and its dehydrating effect is mild and long-lasting, generally without rebound effect.

(4) Pay attention to calorie replenishment and water, electrolyte, and acid-base balance. For comatose patients, those with gastrointestinal bleeding, or severe vomiting, fasting for 1-3 days is recommended, with intravenous nutrition and fluid supplementation. The total daily fluid intake should be 1500-2500 ml, and potassium supplementation of 3-4 g daily is necessary. Whole blood, plasma, and albumin or other colloidal solutions may be administered if needed.

(5) Prevention and treatment of complications. Maintain a clear airway to prevent aspiration pneumonia or suffocation. Administer oxygen and suction sputum if necessary. Regularly turn the patient and perform back percussion. If excessive respiratory secretions affect breathing, a tracheotomy should be performed.

3. Surgical treatment. Craniotomy to remove the hematoma or hematoma aspiration is performed to eliminate the hematoma, relieve pressure on brain tissue, effectively reduce intracranial pressure, improve cerebral blood circulation to save the patient's life, and aid in the recovery of neurological function. Surgery should be performed as early as possible if indicated.