whats going on with this patient?

[FriarMedic]

I had a very interesting EMS call this evening that I'd like to present below and perhaps some of you could tell me how you would take over the patient from my hands at the ED and what you'll be thumbing through for differential diagnoses.

 

50 y/o asian female patient found supine in bed, incontinent. pt responsive to verbal stimuli not answering most questions. patient presents with left side flaccid, no grip strength in left hand, unable to lift/hold left arm in air, skin cool with mild diaphoresis. pupils sluggish with right sided gaze preference. patient has mild-moderate bilateral swelling/puffiness around eyes, lips, and tongue, no uticaria present. BP 170/80, HR 80 NSR, o2 sat 100% lungs clear bilateral, BGL 109.

 

Patient hx from husband- onset of symptoms 15 minutes ago. patient was in kitchen eating (no new foods), complained of sudden onset headache followed by weakness left side, ambulated to bed and laid down. husband left room to call 911. husband denies any allergies for patient. Only medication is HCTZ and only hx is HTN.

 

Upon extrication from residence in stair chair patient is unable to hold self up in chair, vomits whole food bolus/noodle dish. no alcohol odor noted.

 

treatment en route: monitor, IV NS, zofran 4mg

 

deteriorating to responsive to painful stimuli only. patient is presented to ED.

 

First action in ED was intubation. Fresh bite marks to cheek and tongue noted. X-ray to confirm placement, then CT. I'll be following up tomorrow for outcome.

 

But just wondering your thoughts and what else you would do in the ED for this patient. Most signs point to a bleed but how do you explain the facial swelling, incontinence and vomiting? My other thought was perhaps the bleed induced a seizure (bite marks to mouth, presenting post-ictal state, incontinence), but still cant explain the swelling. Some kind of toxin?

[rev ronin]

Subarachnoid hemorrhage can present with seizures and vomiting. With a "sudden onset headache", HTN hx, and one-sided deficits, that's almost archetypical. There's a reasonable chance that she's died, unfortunately.

 

Can you elaborate on the swelling you observed a bit more? Did you happen to see a recent picture of the patient to compare to her post-event appearance?

[laarnie1231]

I suspect intracerebral hemorrhage specifically hemmorrhagic stroke due to history of HTN. The nausea, vomiting and seizure are caused by increase intercranial pressure in the brain. This ICP could also be a cause of her facial edema, although I'm not sure about this. Aside from intubation, administration of Mannitol IV is invaluable to decrease ICP. Antihypertensive meds, anticonvulsants, and fluid maintenance are also necessary.

[cobramarty]

Need to check labs, plts, coags, BS, lytes, EKG.

If there is no bleed, Do you give her TPA?

Do you transfer to a 'stroke center', Do you have neurosurgery available?

[Duluth]

How much NS was given en route, why are we giving isotonic volume to what looks like a hemorrhagic CVA?

 

CT, if absent bleed then TPA.

 

Admit to ICU of stroke center. Have them work it out. Done.

[ventana]

call code neuro - stat CT head with out contrast - ABC's - call neuro for TPA consideration

 

patient is stroking clinically and time is of the essence - some places doing stat MRI's

 

all sounds related to right side CVA (and a big one at that in has face, arm, leg invovlement along with MS changes)

[laarnie1231]

Anyone can explain the facial swelling on this patient? Am I right to assume that this is coming from increase ICP due to brain edema?

[bradtPA]

More likely I think the swelling is from facial trauma post seizure. This sounds like a grade 4 SAH, 80% mortality....