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 in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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