Immediate evaluation

History

Although not often possible, attempts should be made to differentiate trauma from spontaneous hemorrhage. Airway, breathing, circulation (ABC)

A rapid assessment of the airway, respiration, blood pressure, and pulse, with intervention if necessary, forms as important a part of the evaluation of patients following intracranial hemorrhage as with any other critically ill patient. If in doubt about the airway and respiration of a comatose patient (not localizing pain), it is probably better to secure the airway before further deterioration. Care must be taken in all patients to ensure that PaCO2 levels are normal or low to prevent cerebral vasodilatation, which acts to increase intracranial pressure. Hypoxia and hypotension must also be corrected. However, great care must be taken in the treatment of hypertension, as this may be a physiological (Cushing) response to raised intracranial pressure. Treatment of this, in the face of disordered autoregulation, would reduce cerebral perfusion pressure and thus induce cerebral ischemia.

Conscious level

A brief assessment of the conscious level will have taken place as part of examination of the airway. However, a more detailed appraisal is useful at this stage as a guide to the severity of the hemorrhage and the presence of raised intracranial pressure.

The Glasgow Coma Scale (GCS) (Ie§sdaieand..l..J§0D.§ti..1 although developed for use after head injury, provides a useful numerical value for the level of consciousness in any patient. It is based on the best motor response, verbal response, and level of eye opening. A normal conscious level will score 15 ( TableJ). Aphasia and hemiplegia are common findings in patients following intracranial hemorrhage and may reflect local destructive damage. Thus the best motor response (of the non-plegic limbs) is the most accurate assessor of the conscious level. This examination must be repeated at regular intervals and particular attention paid to the deteriorating patient. A falling GCS usually indicates rising intracranial pressure, and appropriate intervention should be taken (hyperventilation, osmotic agents, surgical intervention).

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Table 1 The Glasgow Coma Scale

Pupillary size and reaction

Pupillary size and reaction reflect a balance between the parasympathetic (constrictor) and sympathetic (dilatory) pathways in the afferent optic nerve, the efferent oculomotor nerve, and the ciliary ganglion. Although hemorrhagic lesions in the thalamus and brainstem produce abnormalities, raised intracranial pressure, transtentorial herniation, and compression of the oculomotor nerve will produce ipsilateral pupillary dilatation and eventually an unreactive large pupil. Thus an immediate assessment of the pupils can provide information about the location of any hemorrhage and act as a guide to tentorial herniation from raised intracranial pressure. Repeated examination will detect any increasing mass lesion, particularly in the paralysed patient.

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