1. A Case Study

2. 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?

3. CAM-ICU CT Scan NIH Stroke Scale

4. CBC CMP PT/INR Ammonia ABG

5. 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?

6. Mannitol: decrease intracranial pressure Vasopressors: increase blood pressure and constrict cranial vasculature to reduce bleeding Vitamin K: lower coagulation levels and reduce intracranial bleeding

7. 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

8. 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.