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Management of Intracerebral Hemorrhage
14 Plays6 years ago
Intracerebral hemorrhage (ICH) affects more than one million people annually, worldwide, and is the deadliest and most disabling type of stroke. In this episode of Critical Matters we will discuss the critical care management of ICH.
Our guest is Dr. Sayona John, Associate Professor in the Department of Neurological Sciences at Rush Medical College. She is a practicing neurointensivist and also serves as the Head of the Section of Critical Care Neurology and Medical Director of the Neuroscience Intensive Care Unit & Neuroemergency Transfer programs at Rush University Medical Center in Chicago.
Additional Resources:
AHA 2015 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: http://bit.ly/33ovvZo
The ICH score: a simple, reliable grading scale for intracerebral hemorrhage: http://bit.ly/2rsRh0G
ICH Score Calculator: http://bit.ly/2OotfNx
Music Mentioned in this Episode:
Brother in Arms by Dire Straits: https://amzn.to/34pMxYj
Money for Nothing by Dire Straits: http://bit.ly/34pAWZ9
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
Speaker
And now your host, Dr. Sergio Zanotti.
Understanding Intracerebral Hemorrhage
00:00:32
Speaker
Intracerebral hemorrhage affects over a million people annually worldwide and is the deadliest and most disabling type of stroke.
00:00:40
Speaker
With the growth of comprehensive stroke programs and neurointensive care units, many of these patients are treated in specialized units dedicated to brain injured patients.
00:00:49
Speaker
However, a large number of stroke patients are admitted to general medical and surgical ICUs.
Meet Dr. Sayona John
00:00:54
Speaker
Today, we will discuss the critical care management of acute intracerebral hemorrhage.
00:00:59
Speaker
This is a continuation of a previous discussion
00:01:02
Speaker
we had on ischemic strokes, and our guest again is Dr. Sayona John.
00:01:07
Speaker
Dr. John is an associate professor in the Department of Neurological Sciences at Rush Medical College.
00:01:12
Speaker
She is a practicing neurointensivist and also serves as the head of the section of critical care neurology and medical director of the Neuroscience Intensive Care Unit and Neuroemergency Transfer Programs at Rush University Medical Center in Chicago.
00:01:26
Speaker
Her research interests involve ischemic and hemorrhagic stroke,
00:01:30
Speaker
It's a great pleasure to have her back on the podcast.
00:01:32
Speaker
Sayona, welcome back to Critical Matters.
00:01:35
Speaker
Thank you for having me again.
Classification and Risk Factors of Hemorrhages
00:01:37
Speaker
So I think that today we're going to shift gears a little bit and talk about a type of stroke that is less frequent than ischemic stroke, yet much deadlier and causes a lot more disability, which is acute intracranial hemorrhage.
00:01:52
Speaker
So maybe we could start by an overview of how you classify or how you think about intracranial hemorrhages in general.
00:02:00
Speaker
Sure.
00:02:01
Speaker
So intracranial hemorrhage or intracerebral hemorrhage is about 10 to 15% of all of the stroke subtypes that we see.
00:02:08
Speaker
The problem with intracerebral hemorrhage is that it does carry a disproportionately higher risk of death and long-term disability.
00:02:16
Speaker
And because of that, it becomes an emergency.
00:02:21
Speaker
And unfortunately, it still remains without any sort of an approved acute treatment that has any real benefit for patient outcomes.
00:02:31
Speaker
So generally speaking, the etiology for most of the hemorrhages that we see is hypertension.
00:02:39
Speaker
So it really comes down to good management of the primary risk factor, which is hypertension.
00:02:46
Speaker
And in younger patients,
00:02:48
Speaker
In particular, patients who decide to take themselves off of antihypertensive, they are at two times the risk for developing an intracerebral hemorrhage as a result.
00:02:57
Speaker
Other than hypertension, the other common reasons for a primary intracerebral hemorrhage is, of course, drug use, in particular, any drug that can cause the blood pressure to rise, cocaine in particular, and other underlying risk factors like diabetes.
Diagnosing Intracerebral Hemorrhages
00:03:15
Speaker
Now,
00:03:16
Speaker
Primary intracellular hemorrhage, of course, has to be distinguished from secondary intracellular hemorrhage.
00:03:22
Speaker
And when I say secondary, what I mean by that is, is there an underlying tumor?
00:03:26
Speaker
Is this related to cerebral amyloid angiopathy?
00:03:30
Speaker
Or is this related to any sort of a vascular malformation, either an aneurysm or an ABM?
00:03:35
Speaker
But the much more common ideology that we see for patients presenting with intracellular hemorrhage is hypertension.
00:03:43
Speaker
Excellent.
00:03:43
Speaker
And I think that we can maybe start
00:03:46
Speaker
by talking about diagnoses, obviously the presentation might be similar to other types of strokes or to other types of neurological acute injury, but how do you recommend that the initial workup be conducted or what are the things that we need to be thinking about when we see these patients for the first time?
00:04:07
Speaker
So most of these patients are presenting with an acute onset of a neurological deficit and that could be, again,
00:04:16
Speaker
face arm like weakness, or they could be presenting with decreased mental status.
Vascular Imaging Considerations
00:04:23
Speaker
So the only way to distinguish what you're looking at is really by the basis of a CAT scan.
00:04:29
Speaker
So all of these patients will need a STAT CT to distinguish whether you're looking at a hemorrhage or an ischemic stroke.
00:04:38
Speaker
Oftentimes hemorrhages are described as being associated with a severe headache.
00:04:43
Speaker
that really isn't all that typical in an intracerebral hemorrhage presentation.
00:04:48
Speaker
That is much more typical of a subarachnoid hemorrhage presentation.
00:04:52
Speaker
So using headache as the marker of a hemorrhage versus a non-hemorrhage isn't always helpful.
00:05:00
Speaker
And is there any value of other modalities in the early diagnosis?
00:05:07
Speaker
So I think that
00:05:09
Speaker
Clearly, with anybody who presents with suspected stroke or acute neurological injuries, like you said, having a very time-sensitive approach to getting the CAT scan as soon as possible can quickly classify that patient, right, into different categories that will alter their therapeutic route.
00:05:26
Speaker
But once we confirm it's an intracranial hemorrhage, are there other tests that you think are immediately necessary or any additional imaging that
Prognostic Factors and ICH Scores
00:05:35
Speaker
would be of help?
00:05:37
Speaker
So most people are concerned that the hemorrhage is related to some sort of a vascular malformation.
00:05:44
Speaker
I think your question is really asking whether getting CT angiograms is necessary in all of these patients.
00:05:53
Speaker
So this is where the history really counts.
00:05:57
Speaker
If this is a young patient, and when I mean by young, I say anyone less than the age of 50 and does not have a history of hypertension, or this is an atypical location,
00:06:07
Speaker
And I'll talk a little bit about atypical locations in just a minute.
00:06:12
Speaker
Those are the patients on whom you should consider some sort of a vascular imaging.
00:06:17
Speaker
Now, the reason for considering a vascular imaging is the management from a surgical standpoint changes completely if there's a vascular malformation slash aneurysm associated with this hemorrhage.
00:06:30
Speaker
And also the blood pressure goals are different for patients that have a hemorrhage as a result of some form of vascular malformation.
00:06:36
Speaker
Now, atypical location of bleed, I think it is important for all of us to remember that a third of hypertensive hemorrhages can be low bar in its location.
00:06:47
Speaker
So just because the location of the hemorrhage is low bar and there's a history that is consistent with hypertension, it does not mean you have to get vascular imaging in those patients.
00:06:59
Speaker
Or let me clarify that a little better.
00:07:02
Speaker
A low bar hemorrhage with a strong history of hypertension
00:07:05
Speaker
that is more than likely a hypertensive hemorrhage.
00:07:10
Speaker
And what are other of the common locations, I mean, when we think about hypertensive hemorrhages?
00:07:15
Speaker
I think that you're right.
00:07:16
Speaker
I mean, from a non-neurological perspective, if you're not really in tune into this, you might see blood in the brain, and that makes you think of one thing or the other.
00:07:26
Speaker
But really, like you said, there are kind of patterns that are more classical for hypertensive bleeds or for cerebral amyloid angiopathy as well.
00:07:33
Speaker
Is that correct?
00:07:35
Speaker
Correct.
00:07:36
Speaker
So hypertensive bleeds are classically described as a basal ganglia, thalamus, cerebellum, brainstem location.
00:07:44
Speaker
But again, a third of them can be low bar, but then you have to have the history that goes with it.
00:07:53
Speaker
Amyloid angiopathy is seen in older patients and usually above the age of, if it's a young person, relatively young, that'll be above, still above the age of 60.
00:08:04
Speaker
And those are lobar hemorrhages and you would have to still verify that it is based on amyloid angiopathy and that's where an MRI would come in.
00:08:17
Speaker
In an MRI for amyloid angiopathy, you would see the lobar hemorrhage but you also see micro hemorrhages.
00:08:23
Speaker
These are small spots of blood in the cortical locations.
00:08:29
Speaker
If it is a patient who has a hypertensive etiology, you may see microhemorrhages, again, in the classic locations, which is the basal ganglia, the thalamus, the brainstem, and the cerebellum.
00:08:40
Speaker
And anything in particular, Sayona, that you would comment on cerebellar bleeds?
00:08:43
Speaker
I mean, not about the treatment, but just in terms of diagnosis, what you're thinking of.
00:08:48
Speaker
Obviously, we'll talk about their treatment a little bit later.
00:08:52
Speaker
So cerebellar hemorrhages are...
00:08:55
Speaker
again, very common in hypertension as an etiology.
00:09:01
Speaker
And by neuroanatomic description, it's usually at the location used is the dentate nucleus, which essentially means that it is right in the body of the cerebellum.
00:09:13
Speaker
And again, if there's a history, then that is consistent with the hypertensive bleed.
00:09:18
Speaker
Cerebellar hemorrhages are oftentimes just a little trickier because you can also have
00:09:23
Speaker
posterior fossa vascular malformations that are leading to these hemorrhages.
00:09:26
Speaker
So perhaps we will have a higher reason to get a CT-NGO on these patients just to make sure that we're not missing anything.
00:09:37
Speaker
Excellent.
00:09:38
Speaker
And could you talk a little bit about the location and the size of the hemorrhage in terms of how it makes you think of prognosis or perhaps treatment or how you assess that?
00:09:52
Speaker
So the location oftentimes doesn't help us in prognostication as much as the size of the hemorrhage.
00:10:03
Speaker
Infratentorial, that means anything below the tentorium hemorrhages associated with the cerebellum, in particular the brainstem, generally have a poorer prognosis than supratentorial hemorrhages.
00:10:17
Speaker
But more than that, it is the ICH score that helps us do an evaluation of prognosis.
00:10:26
Speaker
And the ICH score takes into account things like the GCS, the volume of the hemorrhage, if there's intraventricular hemorrhage, if the hemorrhage is infertentorial in its location, and the age, and the age cutoff is 80.
Prognostication with ICH Scores
00:10:41
Speaker
If they are greater than 80, then they get a point.
00:10:44
Speaker
And then you calculate out the ICH score based on that.
00:10:47
Speaker
And this is a tool that's freely available on any website.
00:10:52
Speaker
You can just search for the ICH score and how to calculate it.
00:10:56
Speaker
The tricky piece about calculating the ICH score is really measuring the volume of the hemorrhage.
00:11:03
Speaker
And we use the formula A times B times C divided by two
00:11:08
Speaker
where A is the maximum length of the hemorrhage, B is the maximum width of the hemorrhage.
00:11:14
Speaker
And we pick the hemorrhage to measure at the area where you see it at its largest on a CT scan.
00:11:22
Speaker
And C is the number of slices that you see the hemorrhage on.
00:11:27
Speaker
Now, the number of slices you
00:11:31
Speaker
really just take into account the large slices because otherwise you tend to overestimate the size of the hemorrhage.
00:11:37
Speaker
And again, the exact methodology for calculating these are easily available online.
00:11:44
Speaker
And what would be a volume that we consider to be like a bad sign?
00:11:51
Speaker
So depending on which paper you read, the hemorrhage can be considered small.
00:11:58
Speaker
or large, or some people like to qualify that even more by defining it as small, medium, and large.
00:12:06
Speaker
And I come from the school of thought that you really ought to look at it as small, medium, and large.
00:12:12
Speaker
So any hemorrhage that's less than 30 cc is a small hemorrhage.
00:12:16
Speaker
30 to 60 cc is a medium-sized hemorrhage, and greater than 60 cc is a large hemorrhage, no matter which school of thought you're in.
00:12:26
Speaker
And clearly that correlates directly with outcomes in terms of mortality and neurological prognosis, right?
00:12:35
Speaker
So the ICH score, once you've calculated, does help you.
00:12:40
Speaker
The whole concept of the ICH score really is to look at the 30-day mortality rates.
00:12:45
Speaker
And the score goes from one to four.
00:12:49
Speaker
And anyone who has a score of ICH score of one
00:12:52
Speaker
their 30-day mortality is 13%.
00:12:55
Speaker
And if it's an ICH score of four, their mortality at 30 days is 97%.
00:12:59
Speaker
That's a big difference.
00:13:02
Speaker
So something that, I mean, really, I mean, determines, I think, a lot, I'm sure.
00:13:07
Speaker
Right, which is also why it's very important to accurately assess the size of the hemorrhage, because if you overestimate, then you run the risk of giving the patient a higher ICH score, which they don't necessarily fit into.
00:13:22
Speaker
Excellent.
00:13:22
Speaker
So I definitely will put some links in the show notes to this, but I think this is very valuable for people not only to learn how to do it, but to understand what our colleagues are talking about in neurology, neurosurgery, when we talk about ICH scores.
00:13:37
Speaker
Last time we discussed ischemic strokes, Iona, we talked a lot about the NIH stroke scale.
00:13:43
Speaker
Is that something that still has value and applicability to these patients?
00:13:47
Speaker
So we at our institution will document NIH stroke skills upfront, but we don't usually use that as a indication on how to manage these patients.
00:13:59
Speaker
That's just what they presented with.
00:14:02
Speaker
Our emphasis is much more on understanding the ICH score and what we look at overall, because you do have to take into account
00:14:14
Speaker
what other risk factors and complications that they are presenting with.
00:14:19
Speaker
And that usually becomes the gestalt of their management.
00:14:24
Speaker
And I think that in general, these patients are more likely to come to the ICU, right?
00:14:31
Speaker
I mean, having blood in your brain is never a good thing.
00:14:34
Speaker
So unless it's very minimal, I presume that in most hospitals, these patients are coming to an ICU setting.
00:14:40
Speaker
That's correct.
00:14:41
Speaker
And the number one reason for that is many of these patients, in fact, all of them will come in with a high blood pressure.
00:14:49
Speaker
And the high blood pressure is not necessarily the cause, but much rather the effect of the hemorrhage.
00:14:56
Speaker
In the setting of that hemorrhage, it really is about the body trying to perfuse the brain.
00:15:00
Speaker
And it's all about the cerebral perfusion pressures that the body is trying to accomplish to perfuse the brain.
00:15:08
Speaker
So there,
00:15:10
Speaker
usually hypertensive and we do have specific blood pressure goals where we want to maintain them up front and so many of them will need some sort of a continuous infusion to lower the blood pressure.
00:15:22
Speaker
Now with regards to where we want to keep the blood pressure we can talk about that a little bit but I think it's much more important to know that it is necessary to control the blood pressure.
00:15:35
Speaker
So before we talk about targets, I think just the rationale, right, behind, I mean, treating high blood pressure in these hemorrhagic strokes is a little bit different than the discussion we had about blood pressure and sterile perfusion in ischemic stroke.
00:15:52
Speaker
And my understanding is here that the thought is that there's probably less out of regulation dysfunction in hemorrhagic strokes, but also more importantly,
00:16:05
Speaker
you talked about the importance of size being a determinant of outcome and the thought that very high blood pressures can contribute or cause hematoma expansion.
00:16:17
Speaker
Is that the right way to think about it?
00:16:19
Speaker
That is correct.
00:16:20
Speaker
So up to a third of patients can undergo hematoma expansion whether you did anything or not.
00:16:29
Speaker
And while there has not been
00:16:32
Speaker
been a direct association between blood pressure and hematoma expansion.
00:16:37
Speaker
These patients who are coming in with high blood pressures, you really do want to manage it to protect these patients from further expansion of their hemorrhages because if the hematoma expands, then their ICH score changes, their mortality increases.
00:16:52
Speaker
And that's the thought process behind it.
00:16:55
Speaker
And this is an area that has more studies than
00:17:01
Speaker
blood pressure management and ischemic stroke, although I think that my understanding of the studies is that they still obviously have not answered all our
Blood Pressure Management Trials
00:17:10
Speaker
questions.
00:17:10
Speaker
But can we talk a little bit about current evidence and what would be the recommendations in general for approaching this management of blood pressure?
00:17:21
Speaker
The two trials that got published one after the other in 2013 and 2014
00:17:27
Speaker
are the INTERACT-2 trial and the ATT&CK-2 trial, both of which compared the previous American Heart Association guideline of maintaining the systolic blood pressure less than 180 versus lowering the blood pressure to a normal range, which is less than 140.
00:17:46
Speaker
And both of these trials, unfortunately, did not show any benefit from...
00:17:54
Speaker
decreasing the blood pressure to normal ranges, in particular with regards to hematoma expansion and or outcomes.
00:18:04
Speaker
Now, the ATT&CK trial was stopped early because of the complications associated with lowering the blood pressure.
00:18:13
Speaker
And the INTERACT trial, when they did a secondary analysis, they did find that some patients did have improvement in their functional outcome and the blood pressure was controlled better.
00:18:24
Speaker
However, the caveat to all of this is that in both of those trials, only patients that had small hemorrhages for whatever reason were included.
00:18:35
Speaker
So the guidelines changed to say that if the patients met criteria as determined by the ATT&CK and INTERACT trial, which is small hemorrhages, if you lowered their blood pressure to less than 140, these patients fared better.
00:18:50
Speaker
For everybody else, we're still sticking with the guideline of less than 180.
00:18:55
Speaker
But we do know that greater than 180 does not help patients either because there was no difference in the trial.
00:19:03
Speaker
So what we at our institution do is every patient across the board that presents with an intrasalable hemorrhage will at a minimum have their blood pressure lowered to less than 180 and preferably to less than 160.
00:19:16
Speaker
And what do you usually use to accomplish this?
Managing Blood Pressure in Hemorrhage Patients
00:19:21
Speaker
Sometimes all you need is intermittent pushes of medication, but because we want to consistently maintain the goal and not have them go over it, we will use IV infusions.
00:19:34
Speaker
And your options are calcium channel blockers or beta blockers.
00:19:39
Speaker
The side effects of using beta blockers are slightly higher than using calcium channel blockers.
00:19:45
Speaker
So in general, most of us use either nicardipine or cleftipine.
00:19:51
Speaker
And I think that just to summarize, so currently the way to think about this is that we are a little bit more aggressive than we would in situations with ischemic stroke, that for small hemorrhages, usually keeping it normal below 140 is what the studies have suggested.
00:20:09
Speaker
And for larger or medium hemorrhages, definitely keeping it below 180, but a lot of people probably are targeting more towards 160, 150.
00:20:20
Speaker
with the use of drugs such as necartipine that will give you steady control over blood pressure over time.
00:20:25
Speaker
That is correct.
00:20:27
Speaker
What about just some comments in terms of airway management?
00:20:31
Speaker
We talked a little bit about this in the last episode that we were together, but I presume that these patients maybe as a whole have more likelihood of having GCSs that are very low up front.
00:20:46
Speaker
How do you manage the airways, anything in particular that you think about when intubating these patients or when to intubate these patients?
00:20:55
Speaker
All of our indications for intubating patients really comes down to, again, the GCS.
00:21:02
Speaker
And if the GCS is nine or less just using the traumatic brain injury guidelines, you should consider intubating these patients.
00:21:11
Speaker
also the size of the hemorrhage, the amount of midline shift, the risk they are at herniation, all of these factors also play into the indication for intubating these patients.
00:21:22
Speaker
Rapid sequence is what we use.
00:21:24
Speaker
And again, the key thing is to prevent them from getting too hypertensive or dropping their blood pressure because we want to perfuse the brain.
00:21:33
Speaker
That would really be the key consideration to that intubation.
00:21:37
Speaker
Okay, excellent.
Reversing Coagulopathy in Hemorrhage
00:21:39
Speaker
So one of the issues that I think is growing in terms of complexity is that I presume that maybe a fifth or a fourth, 20-25% of these patients or maybe a little bit less, will have acquired coagulopathies based on the proliferation of all sorts of anticoagulations for cardiovascular diseases.
00:22:03
Speaker
Can we talk a little bit about how you approach a reversal of coagulopathy in these patients?
00:22:10
Speaker
Sure.
00:22:11
Speaker
But before I get into coagulopathy, I also want to address the dual antiplatelet use because a lot of people with coronary artery disease have stents and are on dual antiplatelets.
00:22:22
Speaker
And that's also equally challenging.
00:22:26
Speaker
So the largest trial that we have is the PATHS trial, which looked at giving platelets to patients who are on dual antiplatelets and found no benefit.
00:22:34
Speaker
But really just the risks associated with platelet transfusions, outcomes were actually worse in patients who got platelets than the ones who didn't.
00:22:43
Speaker
There's also another trial that addressed using DDAVP in these patients and again found no benefit.
00:22:49
Speaker
So at this point, the indication for platelet transfusions in these patients would be if there is some
00:22:56
Speaker
plan for surgical intervention, even if it is an external ventricular drain placement, then you can consider giving them platelets right before the procedure, but otherwise there's no indication for reversal.
00:23:07
Speaker
With regards to anticoagulants, at least in where I live in Chicago, we still see a lot of patients who are on warfarin.
00:23:15
Speaker
And the goal for patients on warfarin who are coming with a therapeutic or super therapeutic INR
00:23:20
Speaker
would really be to maintain the INR or get the INR less than or equal to 1.4.
00:23:26
Speaker
And again, these are the Joint Commission requirements.
00:23:29
Speaker
And what is critical for across the board everyone to remember is the fact that a patient coming with a hemorrhage could be on an anticoagulant.
00:23:40
Speaker
And the newer anticoagulants, you cannot look at the lab value and tell whether the patient is on
00:23:49
Speaker
any of the DOACs or not.
00:23:52
Speaker
So it is very important not just to check the COAX, but it's also critically important to get a history and a list of medications because any patient who's on anticoagulants and comes in with a hemorrhage, this is a life-threatening emergency and they need to be reversed irrespective of the size of the hemorrhage.
00:24:11
Speaker
So for warfarin-related hemorrhages, your options are to give FFB or fresh frozen plasma
00:24:19
Speaker
or PCC, prothrombin complex concentrate, along with the vitamin K, because the effect of either of these really only lasts for 24 hours.
00:24:27
Speaker
And the vitamin K is needed to stimulate the liver to produce the factors that they are deficient in.
00:24:34
Speaker
It's not just enough to reverse, you also have to do a weight-based calculation of the reversal and follow that accordingly and recheck the INR to make sure that the INR is at 1.4 or less.
00:24:47
Speaker
Now with the DOEX, there are the newer medications that have come out, some of which are challenging because of their cost associated with it.
00:24:59
Speaker
But for Idurizizumab is available for the Dibigatran related hemorrhage and for the 10A related hemorrhages, you do have the, I'm sorry.
00:25:12
Speaker
And Nexa, is that the conversion then?
00:25:14
Speaker
Yes, thank you.
00:25:14
Speaker
Yes.
00:25:15
Speaker
And DexaNet is available for reversal.
00:25:18
Speaker
But not every institution carries it.
00:25:21
Speaker
And if you do not carry either of these, there are smaller case studies that have shown that PCC is helpful in the reversal of these patients.
00:25:31
Speaker
And I think that what's very important, I mean, one of the things that we do, obviously, as a large group that provides critical care to a lot of hospitals in the community setting is
00:25:42
Speaker
We're very conscious of value and making sure that the therapies that are utilized are cost effective.
00:25:48
Speaker
But I do think that if there is a place to utilize a very expensive direct reversal agent, it would be an intracranial hemorrhage.
00:25:59
Speaker
When you have the history of the use of Xarelto-Eliquis, which are Soxaban or Apixaban, which are very commonly used now, there is one specific drug that can revert them, and that would be
00:26:12
Speaker
I think, the place to utilize it.
00:26:15
Speaker
Absolutely.
00:26:16
Speaker
Because without reversal, these hemorrhages can rapidly expand, and at that point, patients do not survive.
00:26:25
Speaker
And I think that really, I mean, for the clinicians, the important point here to remember, I think, is almost like the pearl, is that the majority of these newer agents you will not determine by the INR.
00:26:36
Speaker
Correct.
00:26:36
Speaker
So if you have a normal INR, but you do not take the time
00:26:40
Speaker
to seek a good history, even if the family's not there, but really make the effort to understand what is the patient on, I think that you could potentially miss something that could be life-saving.
00:26:52
Speaker
Correct.
EVD Use for Hydrocephalus and Hemorrhage
00:26:54
Speaker
So in terms of, since we're talking about the blood already, I guess a lot of the complications that occur downstream or after the patient's admitted relate to intraventricular hemorrhage, complications related to hydrocephalus,
00:27:10
Speaker
increase in intracranial pressure.
00:27:12
Speaker
How do you approach this and how do you manage this in the first hours and make decisions of what needs to be done for that patient?
00:27:21
Speaker
Patients presenting with intraventricular hemorrhage in association with their intracerebral hemorrhage are at a high risk for developing hydrocephalus.
00:27:29
Speaker
And many of them will have hydrocephalus that you can see on their CAT scans even up front.
00:27:36
Speaker
The exams are
00:27:38
Speaker
initially may not necessarily always help you because in the setting of the hemorrhage, the patient's mental status may be on the lower side.
00:27:48
Speaker
So if you see evidence for hydrocephalus on the CAT scan, then that is an indication for placing an external ventricular drain.
00:27:55
Speaker
The external ventricular drain not only helps relieve the pressure and the CSF flow outward as opposed to just staying within the ventricular space,
00:28:06
Speaker
but it also helps eventually with some of the clearance of the blood that's in the ventricular space.
00:28:15
Speaker
Yes, sorry.
00:28:16
Speaker
I was going to ask you if there were other indications, I mean, not based on hydrocephalus that you would consider an EVD as well.
00:28:26
Speaker
So patients who present with thick blood in the ventricular space, even if they don't immediately show signs of hydrocephalus,
00:28:35
Speaker
they will more than likely need an external ventricular drain to help clear that blood because they will develop hydrocephalus at some point or the other.
00:28:44
Speaker
And the longer the blood stays in the ventricular system and the blood breakdown products will continue to cause damage, secondary damage, brain injury.
00:28:55
Speaker
And just in general, outcomes are much worse in patients who have interventricular hemorrhage than the ones that do not have interventricular hemorrhage.
00:29:03
Speaker
So the CLEAR-3 trial looked at using TPA to clear the IVH and compared it to placebo, which was just really normal saline, and unfortunately did not show any benefit of the use of TPA in outcomes for these patients.
00:29:20
Speaker
What it did show, though, was that the incidence of shunt placements was less, and the blood did clear quicker with TPA than it did with normal saline.
00:29:34
Speaker
Is that something that you utilize today or is that something that still needs to be studied further?
Surgical Interventions for Hemorrhage
00:29:41
Speaker
So what we do know is it's safe to use TPA.
00:29:47
Speaker
The study did show that.
00:29:48
Speaker
So in patients who have a lot of intraventricular hemorrhage, we will on a case-by-case basis still consider using TPA to clear the clot out.
00:29:58
Speaker
And the dosing of the TPA because of the associated risk of causing further hemorrhage
00:30:03
Speaker
has to be very, very carefully observed and managed.
00:30:07
Speaker
So it really should be in a center that knows how to use TPA.
00:30:11
Speaker
Absolutely.
00:30:12
Speaker
And in terms of a, you mentioned at the beginning that obviously we don't have any specific therapies, and I guess you could consider an EVD as a surgical intervention, but are there other instances where a surgical evacuation of the hematoma is to be considered or recommended?
00:30:33
Speaker
So the largest evidence or the largest clinical trial that looked at hematoma evacuation in patients presenting with intracebral hemorrhage was the STITCH2 trial, which looked at supraternitorial hemorrhages.
00:30:50
Speaker
In this trial, however, the usefulness of surgery was not proven.
00:30:56
Speaker
The only
00:30:59
Speaker
Indication perhaps is hemorrhages that are close to the cortex that you can get to without having to go through a lot of brain tissue and evacuating those.
00:31:10
Speaker
Perhaps there's some improvement in outcomes in these patients.
00:31:14
Speaker
The current clinical trials are looking at patients for minimally invasive clot evacuation, which is a stereotactic or endoscopic aspiration.
00:31:25
Speaker
which seems to be showing some benefit, but the studies are not published as yet.
00:31:31
Speaker
So for supratentorial hemorrhage, there really is very limited indication for surgery.
00:31:39
Speaker
Now, if the patient is at risk for herniation with a cortical hemorrhage, then absolutely as a life-saving measure, we will consider surgery and hematoma evacuation.
00:31:49
Speaker
But recognizing the fact that outcomes do not really change as a result of that, except
00:31:55
Speaker
it's the difference between mortality or not.
00:32:00
Speaker
So I think that in terms of our management, obviously having neurosurgery on board early in the case we need an EVD is obviously critical, but the likelihood that they would get a surgical intervention seems to be much lower than it was years ago when this was not well studied yet.
00:32:18
Speaker
Correct.
00:32:18
Speaker
The only thing I forgot to mention is cerebellar hemorrhages.
00:32:23
Speaker
They are a completely different disease process from a surgical standpoint because patients who come in with cerebellar hemorrhages should absolutely have consideration for surgical evacuation.
00:32:35
Speaker
These patients do really, really well if they have a relatively large cerebellar hemorrhage and that's evacuated.
00:32:43
Speaker
These patients can actually go back to being completely normal.
00:32:46
Speaker
So that should be considered at all times.
00:32:49
Speaker
That I think is an important point.
00:32:50
Speaker
I mean, in terms of cerebellar,
00:32:52
Speaker
strokes in general, I mean, have a little bit of different therapeutic conducts that I think are mandatory.
00:32:58
Speaker
But like you said, also, these patients have a very good outcome if they've received the time sensitive interventions very quickly, which is something that our audience should be aware of.
00:33:10
Speaker
Can we talk, Sayon, a little bit about management of increased intracranial pressure and perihematoma edema, if that's a big issue?
Managing Perihematoma Edema
00:33:18
Speaker
How do we deal with it?
00:33:19
Speaker
Obviously, with large hemispheric ischemic strokes,
00:33:22
Speaker
Edema is ultimately what can kill these patients.
00:33:25
Speaker
But how does this manifest in the intracranial hemorrhage?
00:33:29
Speaker
In general, patients with intracranial hemorrhage will develop some amount of edema around the clot, which really is that perihematoma edema, but can also develop quite progressive edema, especially with the larger hemorrhages.
00:33:49
Speaker
Unfortunately, the treatment management of these again comes back to do we want to consider some form of surgical decompression at that point to relieve the pressure?
00:34:00
Speaker
Because medically speaking, steroids are not indicated.
00:34:05
Speaker
They do not help in this situation.
00:34:07
Speaker
The other options that you have is managing it with hypertonic saline, maintaining a higher sodium goal and trying to help out in that regard.
00:34:18
Speaker
But hypertonic saline or mannitol or whatever you choose to use really is a situational solution to the problem.
00:34:26
Speaker
It does not help the patient in the big picture, so to speak, because once the sodium levels drop, that hematoma, sorry, edema can continue to get worse.
00:34:39
Speaker
So at that point, it really is a surgical decision.
00:34:44
Speaker
about what to do about the mass effect and the shift as a result of the edema.
00:34:50
Speaker
Excellent.
00:34:51
Speaker
So would it be fair to say that in these large intracranial hemorrhages that are more likely to have significant ICP increases in intracranial pressure from edema, really the use of hypertonic saline of mannitol really bridges to a surgical intervention if we're going to do them.
00:35:07
Speaker
Otherwise, they really don't have a great impact at the medium term?
00:35:12
Speaker
That is correct.
00:35:13
Speaker
Excellent.
00:35:14
Speaker
So I would like to ask you about some additional critical care considerations.
00:35:18
Speaker
And these patients with blood in their brain often, or I don't know if often is the right word, but can present with seizures.
00:35:27
Speaker
And as a resident, I mean, obviously we were always back in the day thinking of seizure prophylaxis in these patients.
00:35:36
Speaker
Could you talk a little bit about how in 2019 we're managing both active seizures, but also seizure prophylaxis in these patients?
00:35:45
Speaker
We have completely moved away from the seizure prophylaxis plan of care in these patients because we don't know whether prophylaxing actually prevents them from having seizures.
00:35:58
Speaker
If they're going to have seizures, we would much rather monitor and see what happens.
00:36:02
Speaker
So none of our patients actually get put on seizure prophylaxis.
00:36:07
Speaker
If they have a decreased mental status, or should I say they have a low GCS and a sizable hemorrhage that is cortical in its location, we will place them on continuous EEG monitoring, sometimes for 48 to 72 hours to make sure that they're not having seizures, because not every seizure that you're seeing in these patients has to be clinical.
00:36:29
Speaker
It could be subclinical.
00:36:31
Speaker
If we find seizures, then we treat the seizures, which is very different from
00:36:37
Speaker
Let's try to protect them from having seizures because we don't know that anything we do makes a difference.
00:36:44
Speaker
Excellent.
00:36:45
Speaker
And what about temperature management?
00:36:46
Speaker
I mean, we talked a little bit about this in ischemic stroke.
00:36:49
Speaker
How do we deal with hyperthermia?
00:36:52
Speaker
Is there any role for hypothermia?
00:36:55
Speaker
Hyperthermia, again, in particular patients who have deep hemorrhages or intraventricular hemorrhage is very, very common in patients presenting with intracranial hemorrhage.
00:37:06
Speaker
So fever, we know, is not good for the brain.
00:37:08
Speaker
So if they start to have fever, you do want to manage them with normothermia.
00:37:13
Speaker
And normothermia really means 37 degrees centigrade, which would then indicate that these patients are getting placed on external cooling in order to manage their temperature in the early phases, which I would say is the first seven days.
00:37:30
Speaker
It is very important also to make sure that it's not an infectious etiology
00:37:36
Speaker
for the fever.
00:37:37
Speaker
So they will all get some sort of infection workup.
00:37:40
Speaker
And if they have external ventricular drains, you also have to be particularly aware that they can develop ventriculitis despite our best efforts at preventing these.
00:37:49
Speaker
So these are all considerations that have to be put into place while you're managing them with normothermia.
00:37:55
Speaker
Eventually, give it a few days.
00:37:57
Speaker
If it's a central etiology for the fever, the fever will resolve and you can normalize the situation.
00:38:05
Speaker
There is no indication for hypothermia in these patients.
00:38:11
Speaker
The only indication would really be if they develop refractory elevations in their intracranial pressure if you're monitoring it.
00:38:21
Speaker
Excellent.
Glucose Management in Brain Injury
00:38:22
Speaker
And along the same lines, how do you think about glucose in these patients and glycemic control?
00:38:28
Speaker
So the principle for glucose management across the board for oral brain injury remains the same.
00:38:35
Speaker
We do not believe in tight glucose control.
00:38:38
Speaker
Our parameters are usually, we tolerate it up to 180 only if they're consistently over 180 would be considered an insulin infusion to manage the blood sugar.
00:38:49
Speaker
The goal of using the infusion is the titrate ability and the shorter action of the insulin as opposed to putting them on longer acting insulin
00:39:00
Speaker
while they are still sick and might require all kinds of sometimes surgical procedures.
00:39:07
Speaker
Sometimes we have to make them NPO so that it just becomes easier to manage it with an infusion as opposed to longer acting insulin.
DVT Prophylaxis in Hemorrhage
00:39:17
Speaker
And what about DVT prophylaxis?
00:39:18
Speaker
So, Yona, I know that these patients obviously have a high risk of having a thrombin' biologic disease, but they also have blood in their brain.
00:39:25
Speaker
How do you
00:39:27
Speaker
start that and when do you think it's safe to do a chemical prophylaxis?
00:39:32
Speaker
Every patient on admission will get placed on some sort of mechanical DVT prophylaxis and by that I mean either sequential compression devices or those compression socks.
00:39:45
Speaker
Everyone will get placed on it right away.
00:39:48
Speaker
Once we know that the hemorrhage is stable because there's a risk for hematoma expansion within the first 24 hours,
00:39:55
Speaker
And we have a repeat scan that shows stability that then will give us the clearance to start DVT prophylaxis.
00:40:03
Speaker
So we're actually quite aggressive about starting DVT prophylaxis and we do it within 24 hours.
00:40:09
Speaker
And in our institution, we actually use the higher dose DVT prophylaxis, which is Q8 hours, just because of the high incidence of DVT in stroke patients that are bed bound.
00:40:20
Speaker
And
00:40:21
Speaker
Generally, we do not run into any complications as such, but every institution has its protocol and twice a day, DVT prophylaxis is just fine.
00:40:31
Speaker
In patients who have hemorrhages, we prefer to use heparin for DVT prophylaxis as opposed to Lovenox just because if the hematoma expands and there's concern that it's the heparin that's doing it and the PTT is elevated, that we actually can reverse the effect of the heparin.
00:40:48
Speaker
Excellent.
00:40:49
Speaker
So one of the topics that we were chatting before we started the recording that I think is very, very important to discuss is this whole, I know that there's been studies that have shown that patients obviously who have, are made DNR very early or who and whom we make decisions of goals of care very early in their, to the ICU with intracranial hemorrhage end up having obviously a significantly higher mortality.
00:41:17
Speaker
That is just an association, but I think it does bring to the front line the whole idea of the self-fulfilling prophecy that we've seen with other neurological diseases that if we kind of give up on these patients too early, we obviously are going to prove to ourselves that they have a bad prognosis because we're not doing the interventions that could bend the curve there.
Delaying DNR to Improve Outcomes
00:41:38
Speaker
How do you think about this in these intracranial hemorrhages, knowing that they have a poor prognosis, but also knowing that great care sometimes can provide
00:41:47
Speaker
good outcomes?
00:41:49
Speaker
So multiple publications have shown that the number one reason why patients presenting with intraceptal hemorrhage die is because we make them die.
00:41:59
Speaker
It is critically important that we're not discussing any goals of care or DNR status, at least for the first 24 to 48 hours.
00:42:09
Speaker
Supporting these patients medically can oftentimes
00:42:14
Speaker
buy us enough time to truly see what their exam and their scans evolved into.
00:42:22
Speaker
The caveat to all of this is if patients present with massive hemorrhages and have already herniated, then obviously you can't bring, you can't salvage that situation.
00:42:35
Speaker
But for everybody else, it is important that we provide full critical care to these patients
00:42:42
Speaker
for the first few days and see how they turn around.
00:42:45
Speaker
Many of these patients surprise us with how they do.
00:42:49
Speaker
So taking into account their IC8 score, which you can use, but then remember it's a 30 day mortality that you're looking at, not an immediate mortality.
00:43:00
Speaker
And how a couple of days of complete care, how the patients respond to that would really be the determining factor.
00:43:12
Speaker
And I think that this is very important because it's a balance for the critical care physician.
00:43:16
Speaker
I think that it is true that for many disease processes and for many patients, we have offered as a medical profession, not necessarily a given specialty, care that is non-beneficial and that probably just prolongs suffering and agony.
00:43:35
Speaker
I think that what's important is also to understand at what point we can be more confident
00:43:41
Speaker
about outcomes and we're never going to be absolutely confident because unless somebody's brain dead, you never know obviously.
00:43:48
Speaker
But I think that the message that I'm hearing, Sayona, is that unless you have very, very extreme cases where there is clearly a non-survivable injury or bleed, massive bleed, super high ICH score, signs of herniation, et cetera, et cetera, providing
00:44:10
Speaker
All these interventions that we talked about in the first 24 hours before having any further discussions in 48 hours really, I mean, allows us to feel more comfortable and confident about who really has a chance to have any type of meaningful recovery versus people who really should be made more comfort.
00:44:30
Speaker
Is that correct?
00:44:31
Speaker
That is correct.
00:44:33
Speaker
And many a times in talking to families, they may still choose to continue with full care.
00:44:41
Speaker
And we have seen patients come back in six months and a year that we never anticipated would survive this injury.
00:44:50
Speaker
And I think what's important always in medicine is to have that humility.
00:44:56
Speaker
and understand that we believe maybe that this is the right path, but we are never sure since there's so much things that we don't understand.
00:45:04
Speaker
And really, I think focusing on the right questions than having all the right answers.
00:45:11
Speaker
Correct.
00:45:13
Speaker
Well, you know how this usually ends, Sajona, but I think that if it's okay, we're going to go ahead and do some closing questions that will be a little bit different, obviously, of what we talked last
Book Recommendation Follow-up
00:45:23
Speaker
time.
00:45:23
Speaker
By the way, the book you recommended on Lincoln, I read it and it was phenomenal.
00:45:28
Speaker
Oh, thank you.
00:45:29
Speaker
I'm glad you enjoyed it.
00:45:31
Speaker
So my first question is, if you were on a very long trip or on a desert island and you could only listen to one music album, which one would it be?
Dr. John's Favorite Music
00:45:41
Speaker
So this is a really tough question because I listen to music.
00:45:48
Speaker
of all different genres and to narrow it down to one album is very, very tricky.
00:45:56
Speaker
However, this is what I came up with.
00:45:59
Speaker
So that would be Dire Straits, Brothers in Arms.
00:46:03
Speaker
And the reason for that is because that's what I listened to in my first year of medical school.
00:46:09
Speaker
And it brings me great joy.
00:46:12
Speaker
And I think that's what I would default to.
00:46:16
Speaker
So that was actually a great year in music.
00:46:19
Speaker
That year you had Born in the USA.
00:46:24
Speaker
I also remember that I was a big fan of Tears for Fears back then.
00:46:28
Speaker
The big chair.
00:46:30
Speaker
So 1995, I mean, I think musically for me also was a very special, a very special year.
00:46:35
Speaker
So excellent, excellent choice.
00:46:37
Speaker
So we'll definitely put a link for those millennials who don't know about Dara Straits.
00:46:42
Speaker
And this is also the,
00:46:43
Speaker
the advent or actually the hype of MTV.
00:46:48
Speaker
And I remember the video associated with this album were like phenomenal and they were like earth shattering back then.
00:46:56
Speaker
So maybe some of our millennials need to check this out.
00:47:00
Speaker
I agree.
Educational Outreach in Hemorrhage Care
00:47:02
Speaker
So the second question, changing gears and going a little bit in a different direction, is about failure.
00:47:09
Speaker
And I think that we, especially as clinicians and as physicians, we really are brought up with this very, what I call the fixed mindset and really fearful of failure.
00:47:21
Speaker
But I believe that that failure to some extent should be embraced since it is often the best teacher.
00:47:26
Speaker
Could you share with us a really good failure, one that really taught you something very valuable?
00:47:32
Speaker
Yes.
00:47:33
Speaker
And again, there are many failures in my life, but I wanted to put it in context to our topic today.
00:47:39
Speaker
So 12 years ago, when I first started working out here and we started this transfer program, predominantly most of the calls that we got for transfers were for patients with intrasolubial hemorrhage.
00:47:54
Speaker
And at that time, the importance of reversal was something that just really wasn't commonly understood.
00:48:03
Speaker
So I got called one night at midnight to transfer a patient that had a cerebellar hemorrhage who was on Coubedin.
00:48:11
Speaker
And I wanted this patient reversed.
00:48:14
Speaker
Of course, we didn't have PCC at that time.
00:48:16
Speaker
The only thing available was FFP.
00:48:18
Speaker
And surprisingly, many smaller institutions did not even have FFP.
00:48:23
Speaker
But this was an institution that did, but did not want to keep the patient there long enough to
00:48:29
Speaker
type and match and to get the FFP running before we transferred the patient over.
00:48:34
Speaker
So that conversation went on for about 45 minutes with both sides getting deeply frustrated because that institution believed that the answer to the patient's problem was to transfer them to us, but the transport would take an hour and a half.
00:48:49
Speaker
And to start at that point to try to reverse this patient with all of the delays associated with FFP,
00:48:55
Speaker
would really mean that this patient would only start getting reversed three hours later.
00:49:00
Speaker
In the meanwhile, the patient deteriorated, had to get intubated and arrived in our ICU bleeding out of the mouth and already herniated with the wife at the bedside who right away told us, just stop everything.
00:49:17
Speaker
And this was a 65 year old CEO of a company.
00:49:21
Speaker
Not that it matters that it was a CEO, but my point being that this was a high functioning gentleman.
00:49:28
Speaker
So this really was a huge failure for me personally that I could not convince the other hospital to do what was right for this patient.
00:49:42
Speaker
And I had to really stop to think about how to approach this because
00:49:50
Speaker
They are calling us, we're grateful for that.
00:49:52
Speaker
We're grateful for the opportunity of the care of this patient.
00:49:55
Speaker
But if we cannot work in conjunction with other physicians and make them understand the importance of doing the right thing for these patients, nobody wins.
00:50:06
Speaker
In particular, the patient does not win.
00:50:10
Speaker
After much discussions with senior stakeholders and with my colleagues, we
00:50:20
Speaker
develop this education program, something akin to what I'm doing right now with you, which is going out there into the community and truly teaching them about the importance of some really small focus things that we just simply cannot afford to make a mistake on.
00:50:43
Speaker
And going at it, not from the position of being in an ivory tower as much as looking at it from the
00:50:49
Speaker
patient's perspective.
00:50:53
Speaker
And I think that's a very powerful story.
00:50:55
Speaker
And as you were relating that, I'm almost thinking that one way to think about this, especially in the community and outside maybe of a large neuro dedicated institution, is that the same urgency that we would apply to giving an ischemic stroke patient TPA, we should apply to giving the reversal
00:51:19
Speaker
and these bleeds that have an anticoagulant history.
00:51:23
Speaker
Absolutely.
00:51:24
Speaker
Would that be a fair way to think about it?
00:51:25
Speaker
Because I think that you're right.
00:51:27
Speaker
I don't think that they would argue with you to give TPA and then send the patient if they could do that, right, in an ED.
00:51:33
Speaker
Exactly.
00:51:34
Speaker
Exactly.
00:51:36
Speaker
And so we still have a lot of work to do with regards to this disease process, which is intracellular hemorrhage, about coming together
00:51:46
Speaker
and knowing everyone should know what you should be looking for.
00:51:52
Speaker
And I think that something that comes to mind when we're talking about this and the point that you made that really there's no specific therapy, but there's a lot of things that we can do and that if we do well, we give the patient a better chance.
00:52:08
Speaker
There's a great article, I think it's called The Bell Curve by Atul Gawande many, many years ago.
00:52:15
Speaker
that talks about how one clinician who dedicated his life to cystic fibrosis took that approach.
00:52:23
Speaker
And the approach was there's no cure for cystic fibrosis, but if we could every little thing fanatically make 5%, 10% better on a compound, it would definitely make a difference for these patients.
00:52:38
Speaker
And I think that the same thing applies to these intracranial hemorrhage patients, right?
00:52:42
Speaker
If everything that we do have, blood pressure control, giving them the reversal, controlling certain things, we can do a little bit better.
00:52:52
Speaker
It adds up, I mean, to a lot that may make the difference for that patient, understanding that the prognosis is still pretty poor for a lot of these patients, but there are some that might be able to return to a normal, high-functioning life.
00:53:05
Speaker
Correct, and have some quality of life.
00:53:08
Speaker
Excellent.
Encouragement for Comprehensive Care
00:53:09
Speaker
So the last question, Sayona, just relates to
00:53:12
Speaker
Is there anything in particular that you want every intensivist listening to this episode to remember to know?
00:53:20
Speaker
And again, it comes down to don't give up on these patients.
00:53:24
Speaker
It's easy to see blood in the scan and then have this approach of, well, there's nothing I can do.
00:53:32
Speaker
Somebody else needs to be able to do something or the neurosurgeon needs to operate on it.
00:53:36
Speaker
And a lot of frustration because neurosurgery will not operate.
00:53:41
Speaker
Good.
00:53:42
Speaker
critical care of these patients is really, really all that's needed.
00:53:47
Speaker
Manage the blood pressure, correct coagulopathy if it exists, and just treat them like every other patient in your ICU.
00:53:56
Speaker
And there is a good likelihood that these patients will do well.
00:54:02
Speaker
And I think that's a great place to stop.
00:54:04
Speaker
And once again, thank you so much for your time.
00:54:07
Speaker
I really enjoy talking to you.
00:54:10
Speaker
I'm probably going to check out my old iPod, see if I still have my dark streaks down there and maybe here's some money for nothing or something along those lines.
00:54:21
Speaker
Absolutely.
00:54:23
Speaker
Thank you so much.
00:54:23
Speaker
Thank you very much.
00:54:24
Speaker
No, thank you for having me.
00:54:27
Speaker
Thank you for listening to Critical Matters, a sound critical care podcast.
00:54:31
Speaker
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00:54:37
Speaker
Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
00:54:42
Speaker
To learn more, visit www.soundphysicians.com.