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 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
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