CICM SAQ 2011.2 Q13
Question
You are asked to admit a 46-year-old man who has just been intubated in the Emergency Department after collapsing from what appears clinically to be a brain stem stroke. His Glasgow Coma Score prior to intubation was 6.
Outline your management strategy for him for the first 24 hours.
Answer
Answer and interpretation
Activate the stroke team if available in this hospital as urgent intervention is needed for the best potential outcome – involves neurologist and interventional neuroradiologist
Attention to ABC (confirm tube position, adequacy of ventilation, control hypertension and treat hypotension to ensure adequate CPP)
Investigations / Interventions
- CT scan to exclude bleed and confirm diagnosis – can miss post fossa and brainstem lesions in the early stages so MRA may be indicated
- Interventional cerebral angiography and thrombectomy if within time window and facilities and resources available.
- Thrombolysis with tPA within 4.5 hours of event if intervention unavailable or unsuccessful
- Heparin infusion
- Aspirin
Physiological monitoring and maintenance of normal parameters (BP, Na, BSL etc)
Role of EVD if hydrocephalus is present
Ongoing neurological assessment – at risk of progressing to locked in syndrome Supportive care of the intubated ventilated critically ill patient
Discussion with family re therapy and outlook plus risk factors for poor outcome
Examination Library
CICM
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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