Nontraumatic Intracerebral Hemorrhage … · Albumin 4.9 g/dL Bilibrubin (total) 0.5 mg/dL Protein...

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Nontraumatic Intracerebral Hemorrhage

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Details Clinical Significance/Impact

History of present illness: Susan Simmon is a 30-year-old Asian female who was transported by ambulance. Her spouse is at bedside. Upon admission to the emergency department (ED) at 20:22, she was following commands, and c/o a severe headache with a pain level of 7 out of 10, tingling and weakness in left arm, dizziness and nausea.

Social History (from Susan and Spouse): Susan lives with her spouse of four years. They have no children and no pets in the home. She works for a large investment banking firm and was recently promoted and transferred to a new location.

Medical History: No significant medical Hx

Family History: Patient states that her mother had migraines and died at the age of 70 after a heart attack. Her maternal grandfather had a stroke at age 69. There is no other family history of stroke or vascular disease, but she has no information about her father’s side of the family.

Current Medications: Estrostep Fe Multivitamin Allergies: NKDA





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Subjective History (Spouse): Spouse states that since Susan was promoted, she has been working far more hours away from home. She is easily agitated and has had difficulty sleeping. Upon arriving home this evening, she c/o fatigue and a severe headache. Minutes later, her spouse found her on the bedroom floor with left sided weakness plus urinary incontinence and called for emergency services.

Objective Data General Appearance: Pt is supine in bed, head elevated 30 degrees, c/o severe headache and nausea. Pt is diaphoretic. VS: Temp: 36.5℃ (97.7℉ BP: 156/88 HR: 90 RR: 22 Ht: 63 inches Wt: 125lbs & 56.8kg RESP: O2 Sat. is 98% on 3 liters/min nasal cannula. Lungs CTA B. No RRS observed. CARDIAC: Regular heart rate with normal S1 and S2. No appreciable murmurs, rubs or gallops. NEURO: Glasgow Coma Scale is 15, opens eyes to voice (E4), oriented to person, place and date (V5), dense left hemiparesis but able to move right side against gravity to commands (M6). Speech is fluent. PEERL (4mm), right gaze preference noted. Left facial droop observed. Babinski sign absent. Patient is right hand dominant. GI: Abdomen soft, nontender, and nondistended with positive bowel sounds. GU: Deferred Musculoskeletal: Deferred Integumentary: Skin pale, cool and diaphoretic. No lower extremity edema.





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Tests ordered by the physician. Rationale/Purpose/Significance

CT or MRI: Head

Chemistry Panel

CBC

Urine Toxicology Screen

Coagulation Profile

Chest X-ray

EKG

Anticipate ED Orders Clinical Significance/Rationale

NPO

Strict Bedrest

Neuro check q 15 min





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Diagnostic Tests, Results and Rational

Test Results Rationale/Significance of Results

Urine Toxicology Screen

Negative for ETOH,

amphetamines,

barbiturates,

benzodiazepines, cocaine,

heroin, Phencyclidine

(PCP), and

Tetrahydrocannabinol

(THC).

PT/PTT PT: 14.5 sec

PTT: 27 sec

INR: 1.1

CBC W/Diff & PLT

WBC 5.2 K/mcl RBC 4.66 M/mcl Hgb 14.1 g/dl HCT 42.7 % MCV 91.6 fl MCH 30.3 pg MCHC 33.0 g/dl RDW 12.7 % Neutrophil (Neut) 50 % Lymphocyte (Lymph) 36 % Monocyte (Mono) 8 % Eosinophil (Eos) 5 % Basophil (Baso) 1 % Neut, Absolute 3.5 K/mcL Lymph, Absolute 2.5 K/mcL Mono, Absolute 0.6 K/mcL Eosl, Absolute 0.4 K/mcL Baso, Absolute 0.1 K/mcL Platelets 329 K/mcl





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Chemistry Results Screen for possible hypoglycemia or electrolyte imbalances BUN 14 mg/dL

Creatine 0.93 mg/dL

Na 145 mmol/L

K 5.0 mmol/L

Cl 103 mmol/L

Ca 10.0 mg/dL

Glucose 83 mg/dL Non-fasting glucose is WNL

Albumin 4.9 g/dL

Bilibrubin (total) 0.5 mg/dL

Protein (total) 7.1 g/dl

ALT 27 U/L

AST 26 U/L

ALP 91 U/L

eGFR non-AA 70 mL/min/1.73m2

eGFR-AA 81 mL/min/1.73m2

CT: emergency, w/o contrast

CT demonstrated acute hemorrhage in right frontal lobe, associated with vasogenic edema, and right-to-left midline shift. Presence of sulcal effacement suggests diffuse cerebral edema.

CT scan results indicate acute intracerebral hemorrhage with diffuse cerebral edema.





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Family Education

What education is essential to communicate to

Susan’s friends & family right now?

Family and friends should be made aware of the additional diagnostic procedures that may be necessary, the course of treatment, and possible adverse effects of this diagnosis:

Case Study Continued Rationale/Purpose/Significance

Soon after the CT, Susan became more lethargic with episodes of bradycardia to the 30s, without concomitant hypertension. She was subsequently intubated and given propofol and rocuronium. In addition, 50 grams of mannitol was administered IV. Once intubated, the Propofol infusion was titrated to maintain deep sedation. She was then moved to the neurological intensive care unit (NICU).

• Patient was intubated to:

• The presence of increased ICP:

• Propofol and rocuronium administered routinely for:

• Mannitol was administered to:

• Mannitol total effect takes how many minutes?

• Propofol titration is administered to maintain:





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Neuro ICU orders written. Rationale/Purpose/Significance

Position in semi-fowlers

VS q 15min

Finger stick glucose q 6hr

Strict I&O

Neuro checks q 15min

Tests ordered by the physician Rationale/Purpose/Significance

Blood gases

Repeat CT or CTA


Over a period of hours, while in the Neuro ICU, the patient’s GCS declined from 15 to 8. Given Susan’s deteriorating neurological status, a parenchymal fiber optic bolt was placed. Her initial ICP was 30 mmHg. She received an IV bolus of 50 grams of mannitol and 500 mL of 3% saline. Thereafter, 250 mL of IV 3% saline was administered every 6 hours. A radial arterial catheter was placed to maintain a cerebral perfusion pressure (CPP) between 60 and 80 mmHg with norepinephrine IV drip titration. Sedation with propofol and fentanyl was discontinued. IV phenytoin was initiated: loading dose of 700mg, then maintained with 100 mg IV infusion every 8 hours. Continuous electroencephalogram (EEG) monitoring was started and angiogram was ordered.

• A parenchymal fiber optic bolt was placed to monitor ICP as indicated by GCS decline. This tool has a lower complication rate, lower infection rate, and no chance of catheter occlusion or leakage (Raboel et al, 2012).

• IV Mannitol bolus administered to decrease ICP- initial reading was 30 mmHg. Normal ICP is 5-15 mmHg

• Hypertonic saline is administered with mannitol when significant cerebral edema or increased ICP is suspected. Hyponatremia can increase Cerebral Edema, hypernatremia can lower ICP (Berger-Pelleiter et al, 2016).

• Arterial line place to maintain CPP at normal (60-100 mmHg).

CPP= Mean arterial pressure (MAP) – ICP

• Phenytoin per drug protocol. Based on 18mg/kg loading dose then maintenance dose of 3-5mg/kg/d (GGC Medicines, 2018).

• EEG monitoring for possible seizure activity.

• Sedation with propofol and fentanyl was discontinued to better assess neurological status.





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Neuro ICU orders written. Rationale/Purpose/Significance

Neuro checks q 15min

VS q 15min

Monitor ICP

Monitor CPP. Call MD if CPP is outside of normal range.

Monitor EEG for abnormal activity

IV phenytoin loading dose of 700mg, then 100 mg IV infusion q 8 hr.

Tests ordered by the physician Rationale/Purpose/Significance

Blood Gases

CBC, Chem panel


Over the subsequent 24 hours, Susan’s ICP climbed up to 40 mmHg, despite multiple boluses of 3% saline and mannitol, heavy sedation, paralysis and targeted temperature management (TTM). Due to refractory ICP elevation, the patient underwent an emergent right fronto-temporo-parietal decompressive craniectomy without removal of the hematoma or AVM. The ICP after the decompressive hemicraniectomy was less than 20 mmHg. She was returned to the NICU. On postoperative day 0 and post-bleed day 1, Susan followed simple commands by showing 2 fingers on the right side.

NICU orders written. Why? Rationale/Purpose/Significance

Continuous monitoring of VS including internal temp probe, during active cutaneous cooling.

Neuro checks q 15 min





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Meperidine 25 mg q3-4h PRN for shivering.

Monitor ICP

Monitor and maintain CCP

Famotidine 20 mg IV bid


On post-op day 7 Susan was transferred to the floor where she has been assigned to you. She is awake, alert, and oriented to person, place and date. She has fluent speech with a mild dysarthria and left facial droop. Sensation is intact and motor strength is intact except for persistent right sided weakness.

What orders do you expect? Rationale/Purpose/Significance

Sequential compression devices

Enoxaparin 40 mg SC once per day

Acetaminophen ii tab q 4-6hr prn

Assisted ambulation

Neuro checks q 6hr

VS q shift

CBC and Chem panel q day





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Post Discharge Care

Patient’s current status at discharge: Susan has not regained pre-event strength back. Ambulates with assistance. Able to grasp items and feed herself. Susan’s sensation intact to light touch. Susan passed a swallow evaluation and was started on a mechanical soft diet. The patient will continue to participate with physical and occupational therapy. On post-op day 15, Susan was discharged to an acute rehabilitation center (ARC).





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Test your knowledge!

Questions 1. How is hemorrhagic stroke different from

ischemic stroke? 2. What is the greatest risk factor associated with

a stroke? 3. What threat does blood from an ICH pose on

the brain? 4. What is Cushing’s triad? 5. What surgical interventions are available to

evacuate an ICH? 6. How is ICP monitored and recorded? 7. How is CPP calculated?

8. Explain the difference between craniotomy and

craniectomy. 9. What are possible complications associated

with a decompressive craniectomy? 10. Will this patient need any additional surgical

procedures related to this recent occurrence? 11. What would be the long term prognosis for a

patient that has experienced this scenario?





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Reference List

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Nontraumatic Intracerebral Hemorrhage … · Albumin 4.9 g/dL Bilibrubin (total) 0.5 mg/dL Protein...

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