Participants
- Ryan Barnicle
- Thanujaa Subramaniam
- Eric Ebert
- Scott Weingart
Minute by minute case
Young woman with spontaneous hypertensive ICH
0:
Pt arrived to the ED
2:
Chief complaint assigned as “Drug Overdose”. Pt roomed to CC bay.
EMS report: 30s yo female found unresponsive in her basement with snoring respirations. Given 10mg Narcan with no improvement. Was last seen at dinner by family and was found 5 hours later.
VSS only notable for hypertension en route. Glucose wnl. Pupils 2mm and equal and no signs of trauma. No blood thinners or recreational drug use per family.
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Q: We have an unresponsive patient. The differential is very broad, including a long list of toxicologic causes, so a more important consideration is what are the next actions you would take? This is a more discrete list of possibilities. Specifically, when do you administer Narcan? When it does not work, what is your threshold for more Narcan?
5:
Initial vital signs in the ED: 96.4, HR 58 , BP 240/111 in R arm, 94% RA, RR 16, End tidal: 40s.
Initial exam: Eyes closed, R>L (4mm, 2mm), sluggish, Groans, BUE loc, BLE wd, GCS: 9. No signs of trauma. LS clear, RR low 20s. Abdomen soft, well perfused, equal pulses throughout. BG 286
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Q: What are you most suspicious for now? Next moves? Do you activate a CODE STROKE? Do you intubate this patient or send them to CT first? Do you start medical treatment for ICH?
Ok, Eric, were you thinking anything our experts did not mention? What was your workup? Did you start treatment?
7:
Labs ordered: BMP, CBC, PT/INR, LFTs, Lipase, VBG lactate, Mg, Phos, Trop, Etoh, UDS, Tylenol, Asa, UA, CPK, Hcg, CO level, CXR
8:
Repeat VS: HR 70, BP 264/126 92% RA
11:
CTA brain and neck, CT c spine ordered
14:
10mg hydralazine given
15:
EKG: sinus bradycardia with rate of 51, LVH with repol changes
<pause>
Q: Let’s talk logistics. You’re sending the patient to CT. You have high suspicion for ICH. What is the exact imaging you are ordering? Are you going with the patient? What are you setting up and ordering for when the patient returns to resus bay?
20:
Pt taken to CT scan with CC team. Saw large R IPH with IVH
<pause>
Q: We have an intracranial hemorrhage – but we should be more specific in categorizing head bleeds. How would categorize this bleed? Medical vs trauma? Why is this important? When the story if ambigious, what findings on CT help differentiate trauma vs medical?
30:
Patient returns to resus room.
Repeat VS: 264/110, 56 95% RA, 101.8kg.
<pause>
Q: How are we going to intubate this patient? Scott – you taught us a lot about neurocritical care intubations and the unique aspects of this procedure. What are the big picture goals of this procedure and how do we get it done? Rox vs sux?
30:
Ordered for Mannitol 100g, 23% HTS bolus, 3% saline gtt, nicardipine, 30mg etomidate, 200mg sux
38:
HTS given, Neurology c/s placed and NSGY paged rec SBP goal <140
<pause>
Q: What are the indications for hyperosmolar therapy? What is the preferred agents? If the ideal agent is not available, are their second line options?
<pause>
Q: What are the latest blood pressure goals for head bleeds? Do they differ based on location? Trauma vs non-trauma? Sometimes we extrapolate medical ICH with TBI. Why is important to think of them so differently?
43:
23% given and 3% gtt started
36:
Pt intubated with glidecope, OG placed, Initial vent settings: PC: 16/5, PEEP 5, FiO2 60%, RR22
<pause>
Q: What are the goals of mechanical ventilation for this patient? What are your settings going to be?
49:
50mcg fentanyl given
50:
Initial VBG: 7.40/ PCO2 50, Lactate 2.1, glucose 336, Na 136, K 3.0, Cl 97, Ca 4.5
50:
CXR: ETT and enteric tube, low lung volumes
58:
Propofol started at 40mcg/kg/min, 30mg propofol bolus given, Nicardipine gtt started at 5mg/min
59:
Repeat VS: HR 121, RR 26, 98% on vent, Cant get an automatic or manual BP.
Pt noted to have bounding pulses!
61:
Trop 16, HCG neg, foley catheter placed
63:
Still cant get BP, A line getting set up
67:
50mg propofol bolus given, prop increased to 50
69:
Nicardipine maxed at 15, prop increased to 60
71:
BMP results: Glu 290, BUN 10, Cr 0.57, Na 136, K 3.7, Cl 94, CO2 28 AG 14, Ca 9.5 alb 4.9, T bili 0.5, D bili 0.1, ALP 102, TP 92, ALT 69, AST 51, Lipase 36, Mg 1.6, Phos hemolyzed, INR QNS, ETOH neg, Tylenol/ASA neg, CPK 180
71
VS: 119, 148/76 (A-line)
72:
Nicardipine to 10 and prop to 40
76:
2g cefazolin ordered – why was this given?
77:
100mcg fentanyl given
77:
Results of CT/CTA brain and CT C-spine:
CTA BRAIN:
Pre-contrast images demonstrate a large 4.1 x 3.2 cm intraparenchymal hematoma with surrounding edema centered upon the right thalamus with intraventricular extension of hemorrhage into bilateral lateral ventricles, third ventricle, and fourth ventricle. There is dilatation of the temporal horns of bilateral lateral ventricles. There is diffuse effacement of the cerebral sulci. There is 5 mm of leftward midline shift.
Intracranial Carotid Arteries: Normal caliber without significant intracranial stenosis.
Anterior Circulation: No aneurysm, vascular malformation or hemodynamically significant intracranial stenosis identified.
Posterior Circulation: No aneurysm, vascular malformation or hemodynamically significant intracranial stenosis identified.
CTA NECK:
Right carotid circulation: There is no evidence of atherosclerotic disease or luminal stenosis.
Left carotid circulation: There is no evidence of atherosclerotic disease or luminal stenosis.
Vertebral Arteries: The bilateral vertebral arteries and basilar artery appear normal for age.
CERVICAL SPINE:
Osseous Structures: There is normal mineralization and alignment with no focal bone lesion or fracture. Vertebral body height is maintained.
Disc space height: Degenerative disc disease at C4-C6..
Facet Joints: Normally aligned with no significant degenerative disease.
Neural Foramina: Patent with no significant osseous narrowing.
Paravertebral soft tissues: Normal.
Visible lung and mediastinum: Normal.
IMPRESSION:
- 4.1 cm intraparenchymal hematoma centered on the right thalamus with extensive intraventricular extension and 5 mm of leftward parafalcine herniation. Distribution is most suspicious for a hypertensive etiology.
-
No underlying aneurysm is identified. No occlusion of the arterial system of the head or neck.
-
No acute traumatic injury of the cervical spine.
<pause>
Q: What are the definitive management options for this patient? Where does this patient need to be? Who needs to be called?
80:
Vent settings adjusted RR 24, delta 18, Ancef given, Pt again hypertensive to 200/100s
81:
Prop increased to 60, nicardipine at 15
85:
50mg propofol bolus given
87:
UA: 3+ glucose, trace ketones, 1+ blood, micro bland
87:
Pt admitted to NCCU
<pause>
Q: Just because the patient is admitted doesn’t mean the care is done. What additional considerations does the ED need to consider from the NCC perspective? How can reduce mortality and morbidity while waiting for the ICU team to take over?
89:
Neurosurgery at bedside placing EVD, still hypertensive
90:
20mg labetalol given
91:
A-line BP 117/67
98:
100 of fentanyl given, cardene decreased to 10
105:
UDS resulted neg
107:
100mcg fentanyl given
124:
Bed assigned in NCCU
130:
VS 127/78, HR 89
134:
Report given to NCCU
138:
LIJ CVC placed.
<pause>
Q: What was the indication for CVC? What is the optimal location for CVC in NCC patients?
144:
BP 135/75, Prop to 60
…EVD placement…
194: Pt taken back to CT after EVD
205: Repeat VBG 7.39/44, lactate 3.1
212:
Repeat CT results:
Intra-axial structures: Similar size of a large 4.0 x 3.1 cm intraparenchymal hematoma with surrounding edema centered upon the right thalamus with surrounding edema. Diffuse cerebral sulcal effacement. Mass effect results in 5 mm of leftward shift midline shift, similar to prior.
Ventricular system: Similar appearance of diffuse intraventricular hemorrhage within bilateral lateral ventricles, third ventricle, and the fourth ventricle. Similar appearance of dilatation of the temporal horns of bilateral lateral ventricles. Interval placement of a left ventriculostomy catheter with tip terminating near the foramen of Monro.
Extra-axial spaces: Normal for age.
Vasculature: The visualized vessels are normal.
Orbits: The visualized orbits are normal.
Calvarium: Left frontal burr hole.
Paranasal sinuses: Appear normal where visible.
IMPRESSION:
- Interval placement of a left ventriculostomy catheter as above.
-
Stable intraparenchymal hematoma centered on the right thalamus with intraventricular extension and 5 mm of leftward parafalcine herniation.
224:
HR 78, BP 146/73, ICP 8
230: Pt taken to NCCU
<pause>
Q: What is the differential for IPH in a young person? In brief, what are the next inpatient diagnostic and therapeutic goals?
Hospital course:
Angiogram was normal with no vascular lesions.
MRI shortly after showed:
Intra-axial structures: Evolving intraparenchymal hemorrhage centered within the right basal ganglia/thalamus with similar surrounding edema and mass effect. Additional 8 mm right parietal parenchymal hemorrhage or surrounding edema which is not
definitely seen on prior CT. Numerous punctate foci of hemosiderin within the hemispheres, basal ganglia, and brainstem. Chronic left pontine, corona radiata, and centrum semiovale infarcts.
Ventricular system: Left frontal ventriculostomy catheter, unchanged in positioning with interval decompression of the right frontal horn and left lateral ventricle. There is persistent dilatation of the right ventricular atrium and temporal horn, which
demonstrate periventricular FLAIR signal hyperintensity. Similar ventricular hemorrhage.
Extra-axial spaces: Scattered superior cerebellar subarachnoid hemorrhage.
Vasculature: The visualized vessels are normal.
Orbits: The visualized orbits are normal.
Calvarium: Normal.
Paranasal sinuses: Appear normal where visible.
IMPRESSION:
- Evolving right basal ganglia intraparenchymal hematoma. Expansion of the hematoma cannot be excluded given the difficulty of direct comparison due to modality differences. Recommend continued imaging follow-up.
-
8mm right parieto-occipital hematoma with surrounding edema, not definitely seen on prior CT.
-
Numerous punctate chronic microhemorrhages in a pattern suggestive of hypertensive microangiopathy.
-
Left frontal ventriculostomy catheter unchanged. Interval decompression of the left lateral ventricle and frontal horn of the right lateral ventricle with persistent dilation of the right ventricular atrium, occipital horn, and temporal horn with
associated periventricular FLAIR signal hyperintensity, concerning for ventricular entrapment.
- Similar ventricular hemorrhage.
-
Scattered superior cerebellar subarachnoid hemorrhage.
During a family meeting, the patient was made DNR.
Patient started seizing, and had propofol and Keppra increased and was loaded with vimpat.
Repeat CTH was stable and cEEG showed “This is most consistent with a diffuse or multifocal cerebral dysfunction with a structural abnormality on the right.”
Patient was made CMO, terminally extubated and passed shortly after.
Additional New Information
More on EMCrit
EMCrit 129 – LAMW: The Neurocritical Care Intubation
Additional Resources
Now on to the Episode
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
Great episode. Logistical question. Where/how do you bolus your initial 23.4% before you get central access? PIV, IO, direct fem stick? I’ve seen some literature that PIV is safe however everywhere that I’ve worked that’s against all nursing protocols. Thanks!
prefer central line or midline. Peripheral is ok if pt is herniating and there is 1 study in the lit demonstrating this.
Scott, how would recommend paramedics perform a Neurocritical care intubation for a suspected CNS emergency (no imaging available before the intubation) in the prehospital setting?
Would you change anything from what you do in the hospital after imaging?
for medics, if the pt requires intubation i would just do an rsi avoiding hypotension and hypoxemia
What’s your method for measuring optic nerve sheath from CT?
doing a wee on it in next couple of weeks
Hi Scott,
May I ask you to expand on your comment around the use of remifentanil in the RSI induction?
You mentioned that this will likely be the choice of medication once it becomes generic/cheaper in the US.
I currently have this medication but use it exclusively in the post-RSI maintenance phase of TIVA of the intubated patient. Are you providing a slow bolus of this medication?
Can you detail exactly how you’re administering this?
Thanks – great Shadowboxing case.
Dean
Hi Scott, what are your thoughts on the efficacy of fentanyl for the RSI/part of post intubation analgesia/sedation in this case? They received 10mg of naloxone when they arrived. Been in a similar situation before and worry that the opioid will have very limited effect given recent use of naloxone.
Thanks
it’s a great point!
Sorry for my anonymity. Ofc I was not at the actual medical theater but quite surprised the patient was DNRed passed away ,given the patient’s young age and hematoma volume.
Was the ICP measured after EVD insertion?
With the existence of IVH, EVD could have stopped functioning and subsequent increase in ICP might led to low CPP.
Unless MRI revealed other cerebral/vascular structural anomaly, NS team could have tried more invasive measures like ICH catheter drainage targeting right basal ganglia.
completely agree with all of that
only have the info presented