Non-surgical treatment of cerebral hemorrhage

  1. Keep quiet. Keeping quiet is conducive to stopping bleeding, preventing or reducing blood breaking into the ventricles and preventing rebleeding, as well as stabilizing blood pressure and intracranial pressure. For this reason, after the patient is transported to a nearby hospital, he should not be transferred to another field, and should be kept absolutely bedridden to avoid non-essential examinations. If the patient is irritable, he or she should first be looked for any adverse stimuli causing it, such as headache, bladder, distention, bed discomfort, etc. Although various sedatives can raise the stress threshold of the nervous system and forcibly control agitation, adverse stimuli should be eliminated according to the specific situation, such as lowering intracranial pressure, lowering blood pressure, catheterizing or applying heat to the lower abdomen to help urination, changing wet bed sheets, and spreading the bedding. If the patient is still agitated, Valium can be used appropriately, but the dose should not be too large, so as not to affect the observation of the level of consciousness, and morphine drugs are prohibited to avoid inhibiting breathing.  2.Absorb oxygen to improve cerebral hypoxia.  3.Keep the airway open. Patients with cerebral hemorrhage mostly have impaired consciousness, so it is easy to have posterior tongue drop (affecting breathing), and there are more secretions in the mouth, throat and trachea, which are not easily discharged, making it difficult to rescue and treat. It should be timely aspiration and removal of secretions to keep the respiratory tract unobstructed, and tracheotomy should be performed if necessary.  4. Early control and reduction of cerebral edema. Acute cerebral hemorrhage has different degrees of cerebral edema, which often peaks within 3-7 days and can cause brain herniation and endanger life, so it is an important link to actively control cerebral edema and reduce intracranial pressure.  (1) 20% mannitol 250ml drip, 30min or so, depending on the condition of every 6-8h, generally used for 7-10 days. The use of mannitol has two purposes, one is to reduce intracranial pressure, and the other is to scavenge free radicals. During the medication period, attention should be paid to urine output, potassium supplementation and monitoring of cardiac and renal functions.  (2) Diuretics: often used in combination with dehydrating agents, generally 20-40mg of tachyphylaxis is added to 30ml of 10% glucose for sedation 2-3 times a day for 3-5 days. Side effects may cause electrolyte disorders and should be corrected with care.  (3) Glucocorticoids can reduce cerebrospinal fluid production, reduce capillary permeability, inhibit antidiuretic hormone secretion and stabilize lysosomal membranes to reduce cerebral edema. Dexamethasone 20mg can be used after sedation, 10mg every 12h intravenous injection; 2 days later reduced to 8mg every 12h intravenous injection; day 5 onwards 5mg every 12h intravenous injection; a total of 7 days as a course of treatment. If combined with diabetes mellitus, upper gastrointestinal bleeding should not be used, the application of hormones during the addition of metformin 0.8 ~ 1.0g/d IV to protect the gastric mucosa, to prevent gastrointestinal bleeding has a certain effect.  5.Stabilize and properly lower blood pressure Overcome the increased intracranial pressure to maintain proper cerebral blood flow, which is an automatically controlled pathophysiological mechanism for regulating cerebral blood flow. If blood pressure is lowered to normal too early, there are the following dangers: (1) reduced cerebral perfusion causing cerebral infarction; (2) chronic hypertensive patients with cerebrovascular autoregulation tolerate the state of high blood pressure, blood pressure is lowered to normal and cerebral blood flow is reduced; (3) patients with atherosclerosis, local vascular stenosis, blood flow is significantly reduced after blood pressure is lowered. Therefore, blood pressure should not be lowered too fast or too low; the original blood pressure level should be referred to, and appropriate drugs should be selected so that blood pressure can be gradually reduced to the original level before cerebral hemorrhage or slightly higher. The requirement of blood pressure lowering should be achieved within 12-24h from the beginning of treatment.  6.Protect brain cells. Put ice cap on the head and ice bag at the carotid artery to reduce the metabolism of brain cells and also reduce the cerebral edema by cooling at the same time. In the drug can be used energy synergist, cytochrome C; can be applied as appropriate brain activator, 1.6-diphosphate fructose, etc.  7, the application of hemostatic drugs. Although it is generally believed that intracerebral hemorrhage is difficult to be stopped by drugs, but for punctate bleeding, oozing blood, especially when complicated by gastrointestinal bleeding, or when accompanied by coagulation disorders and bleeding tendency, hemostatic drugs may play a role, so clinically appropriate for patients with cerebral hemorrhage can be used. For example, hemostatic aromatic acid, anlagen, lithopodium, etc. However, blind application of hemostatic agents has the risk of turning patients with atherosclerosis to suffer from ischemic stroke or myocardial infarction again. Therefore, the need for hemostatic drugs should be based on the situation; the coagulation function should be checked frequently during the use of hemostatic drugs, and the duration of medication should not be too long.  8. Maintain nutrition and water-electrolyte, acid-base balance If the patient is impaired in consciousness and vomiting frequently, he should fast for 1 to 2 days. Intravenous rehydration should not be too much or too fast, and the daily intake should not exceed 2500ml, and should be calculated separately when applying dehydrating agents, diuretics or having high fever; the intake of fluid should be limited to 1500ml for those with complications of heart disease and poor heart function, in order to maintain normal urine volume and specific gravity. After 48h, the fluid can be fed nasally and supplemented with various vitamins. Because most patients with cerebral hemorrhage have hypertension, they should be given low-salt diet and the nasal feeding tube should be changed once a week to prevent esophagitis.  9.Actively prevent and treat complications. It is a problem that cannot be ignored for successful resuscitation. There are more complications in patients with cerebral hemorrhage, such as urinary tract infection, pulmonary infection, central respiratory failure, decubitus ulcer, gastrointestinal bleeding, cardiac dysfunction (cerebrocardiac syndrome, which can appear as arrhythmia, myocardial ischemia, myocardial infarction, etc.), renal failure, etc. While actively resuscitating, attention should also be paid to the detection and timely treatment of these complications.  10.The application of Salvia injection. According to research:Salvia not only has the effect of inhibiting coagulation and activating fibrinolytic system; but also has a regulating effect on fibrinolytic system, which can make the low coagulation state elevated and the high coagulation state reduced, playing a two-way regulating effect; at the same time, it can make the collateral circulation open, capillary network increase, and the vascular pressure at the bleeding site decrease, which is conducive to preventing re-bleeding, and can also make the hematoma absorb. According to the above principles, in clinical practice, patients in the acute stage of cerebral hemorrhage were treated with 5% glucose 250ml+danshen injection 10ml in a sedative drip once a day for 7 to 10 days. The observed results are really helpful to improve the success rate of resuscitation of cerebral hemorrhage and reduce the occurrence of sequelae, which is worthy of clinical attention.  In conclusion, it is difficult to improve the success rate of resuscitation of acute cerebral hemorrhage, especially in the grassroots hospitals with poor medical care, and it is important to continuously summarize the clinical experience and improve the diagnosis and treatment level.