The Neuro Patient

A Case Study

Case Study

A 19-year-old female presents to the ED with a severe headache. Onset was 2 hours ago. History

is negligible. Vital signs are as follows:• BP 88/46• Pulse 130

• Respirations 24• Temperature 98.2

• SpO2 98%

What are your list of differential diagnoses?What else do you want to know?

Tests & Procedures?

• CAM-ICU• CT Scan

• NIH Stroke Scale

Laboratory Tests?

• CBC• CMP• PT/INR• Ammonia• ABG

Results

The results are coming in. The CT scan indicates a large hemorrhage in the right frontal lobe. The

coagulation studies indicate a high INR. The ABG indicates trending acidosis. Your patient is obtunded at this point and vital signs are

plummeting. Current BP is 76/30, Pulse 145 and irregular, Respirations are 30 and agonal.

What medications and procedures do you anticipate?

Medication

• Mannitol: decrease intracranial pressure• Vasopressors: increase blood pressure and

constrict cranial vasculature to reduce bleeding• Vitamin K: lower coagulation levels and reduce

intracranial bleeding

Procedures

• Prepare for intubation and ventilator support• Possible cranial bolt to monitor ICP

• Neuro checks q 15 minutes• EEG

• Possible surgery for hematoma evacuation and/or Burr’s holes

• Frequent vital signs, strict I&O, and preparation for impending code blue

Conclusion

The outcome for these patients is generally poor unless the bleed is quickly identified and

interventions are immediate. A widening pulse pressure, fixed pinpoint pupils, and decerabate

posturing are all indications of brain death. Unfortunately, many of these patients are young

and/or do not have a previous history.