Diagnosis: Hypertensive Intracerebral Hemorrhage

A CT scan of the patient's head revealed a left basal ganglia hemorrhage with intraventricular extension causing midline shift due to early cerebral edema. 

Soon after viewing the CT scan findings the patient began to develop bilateral extensor posturing. Pupils continued to be equal and reactive. A dose of IV mannitol was delivered followed by intubation after pre-medication with IV lidocaine. The patient was hyperventilated to a goal PCO2 <35. Neurosurgery was consulted for emergent placement of an endoventricular device and the patient admitted to the neurological intensive care unit.

Subsequent CT angiogram of the patient's head revealed no evidence of an aneurysm or arteriovenous malformation. A urine toxicology screen was negative for cocaine or methamphetamine. Neurosurgery ultimately diagnosed the patient with a hypertensive intracerebral hemorrhage. It was later learned from the patient's family that she had a history of poorly controlled hypertension, hepatitis C, and regular IV heroin use for the past 5 years. 

ED MANAGEMENT OF ELEVATED INTRACRANIAL PRESSURE (ICP)

RAPID FIRE

Why we care

• Increased ICP --> cerebral herniation --> permanent disability and/or death

Intubation (patient is obtunded, not protecting airway, GCS <8) 

• Perform brief neuro exam before sedating/paralyzing
• Lidocaine 1.5-2 mg/kg IV push
• thought to blunt the increase in ICP due to stimulation of patient's airway 
• controversial, limited data/evidence to back efficacy
• Induction agent = Etomidate
• minimal cardiopulmonary disturbance = minimal ICP disturbance
• Paralytic agent = Succinylcholine (barring obvious contraindications)
• good for rapid onset
• some sources recommend pre-medicating with sub-paralytic dose of a nondepolarizing agent to mitigate fascinations and possible increase in ICP

Hyperventilation

• Goal is to reduce PCO2 to range of 30 - 35 mmHg 
• increases cerebral vasoconstriction --> reduced cerebral blood flow
• onset of effect in 30 sec, peak effect at 8 min
• thought to lower ICP by as much as 25% 

Osmotic Agents

• Mannitol (0.25-1 g/kg) = mainstay 
• reduces cerebral edema by osmotic gradient pulling water out of cells
• effect occurs within minutes; peak effect at 60 min
• lasts 6-8 hours
• Pros
• expands blood volume helping maintain systemic pressure
• promotes cerebral blood flow by reducing blood viscosity 
• free radical scavenger
• Cons 
• hypotension and renal failure in large doses
• increased bleeding into traumatic lesions by reducing hematoma tamponade

• Hypertonic Saline 
• used for increased ICP since 1919
• significantly reduces ICP
• encouraging data showing benefit of continuous infusion of 3% HTS in pediatrics
• Cons
• conflicting data regarding efficacy
• renal failure
• central pontine myelinolysis
• rebound increase in ICP

• Steroids do not lower ICP, some studies even suggest increased mortality

Emergent Neurosurgical Consult

• If patient not responding to above measures then may likely require:
• emergency burr holes (epidural hematoma)
• decompressive craniectomy (epidural hematoma) 
• endoventricular device (expanding intraventricular hemorrhage)

References: 

Heegaard WG, Biros MH, Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 41: Head Injury

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Splitting Headache

A 52 year-old female is being transferred from an outside urgent care clinic to your tertiary care facility for altered mental status. Per the the paramedic's report the patient presented to the clinic about 1 hour ago with chief complaint of headache. Subsequently during her evaluation she became altered and combative. The treating physician called for an ambulance to have the patient transferred for higher level of care. 

On arrival to the emergency department the patient is combative, moving her left side purposefully while withdrawing with her right side. Pupils are equal and reactive on exam. While awaiting your first set of vital signs you are told the patient's blood pressure at the clinic was 210/110. No other medical history is known about the patient. There was no family with the patient at the clinic. 

A CT scan of the head is ultimately obtained and shown below:

What is the diagnosis?

How would you manage this patient? 

Would you intubate? If so what agent(s) would you use for induction?  

Please leave a comment below and share your thoughts. 

The diagnosis for this case will be posted in approximately 1 week.

Diagnosis: Pericardial Effusion and Cardiac Tamponade

Review of the patient's abdominal series revealed a severely enlarged cardiac silhouette interpreted as a large pericardial effusion and/or structural enlargement of the heart.

Based on these findings and echocardiogram was obtained and showed a large pericardial effusion with impending tamponade. An arterial pressure waveform revealed evidence of pulsus paradoxus with a respiratory variation of pressure greater than 10 mmHg. The initial right atrial pressure was 24 mmHg and the initial pericardial pressure was 18 mmHg. 

The patient subsequently underwent pericardiocentesis with a total of 1,720 ml of serosanginous pericardial fluid removed. Following the procedure the right atrial pressure decreased to 18 mmHg and the pericardial pressure to 3-5 mmHg with normal left ventricular systolic function (ejection fraction 60%). 

Inpatient work-up revealed no laboratory abnormalities including a normal troponin level. The patient was placed on a bowel regimen of colace and senna with subsequent bowel movement. He was discharged in stable condition the following day with cardiology follow-up.

Pericardial Effusion and Cardiac Tamponade Rapid Fire

Most common causes of pericardial effusion:

1. viral
2. idiopathic
3. malignancy
4. uremia
5. trauma
6. radiation therapy 

Pericardial effusion can produce an enlarged cardiac silhouette on CXR

• 200-250 ml pericardial fluid necessary to produce cardiomegaly 
• echocardiogram = study of choice for differentiating pericardial effusion from enlarged cardiac chamber size

Treatment of choice for pericardial effusion = pericardiocentesis

• diagnostic and therapeutic 
• guided by echocardiography
• typical studies: protein, glucose, spec grav, cell count, gram stain, culture
• complications: dysrhythmias, pneumothorax, myocardial perforation, coronary artery and/or liver laceration 

Cardiac tamponade = compression of myocardium by contents in pericardium

3 stages necessary for tamponade:

1. fluid filling parietal pericardium 
2. fluid accumulating faster than rate of parietal pericardium's ability to stretch
3. accumulation exceeds body's ability to increase blood volume to support RV filling pressure = decreased cardiac output = badness :( 

When to suspect tamponade:

• Beck's Triad = hypotension, distended neck veins, muffled heart sounds
• any penetrating chest wound
• uremic pericarditis
• progressive or severe chest pain, cough, dyspnea
• Pulsus paradoxus = exaggeration of normal inspiratory decrease in systolic BP 
• inspiration leads to >12 mmHg drop in systolic BP 

10% of all patients with cancer develop cardiac tamponade

ECG = decreased voltage and electrical alternans 

Diagnosis confirmed by echocardiogram

• pericardial effusion + paradoxical systolic wall motion

Management of non-traumatic cardiac tamponade

• volume --> IVF to augment RV filling pressure to overcome pericardial constriction
• pericardiocentesis or pericardial window
• patient may require repeated pericardiocentesis or eventual pericardiectomy
• traumatic cardiac tamponade is better severed by a surgical procedure 
• thoracotomy, sternotomy --> better access, more definitive management
• pericardial blood often clots and fails to drain with pericardiocentesis

Cardiac tamponade = high mortality --> rapidity of diagnosis and treatment matters! 

References: 

Jouriles NJ, Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 82: Pericardial and Myocardial Disease

Eckstein M, Henderson SO, Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 45: Thoracic Trauma

Ugras-Rey SS, Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 123: Selected Oncologic Emergencies

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