CICM SAQ 2015.2 Q26

Question

A 27-year-old female presents to the Emergency Department after a collapse at work that was followed by a brief tonic-clonic seizure. She is 30 weeks pregnant with no previous pregnancies or other significant medical history. She currently localises bilaterally to painful stimulus but does not open her eyes or vocalise.

Her blood pressure is 170/50 mmHg, her urine analysis is unremarkable, and the cardiotocogram (CTG) is ‘reassuring’. A CT brain scan shows a sigmoid and transverse venous sinus thrombosis, with some temporal lobe parenchymal haemorrhage.

  • a) List the major risk factors, other than pregnancy, for this condition. (30% marks)
  • b) Briefly outline the management priorities for this patient? (70% marks)

Answer

Answer and interpretation

a) List the major risk factors, other than pregnancy, for this condition. (30% marks)

  • Prothrombotic conditions – genetic or acquired
  • Oral contraceptive
  • Malignancy
  • Parameningeal Infection e.g. ear, sinus
  • Head trauma
  • Surgery
  • Mechanical precipitant
  • Autoimmune disease e.g. SLE, antiphospholipid
  • Other drugs e.g. androgens

b) Briefly outline the management priorities for this patient? (70% marks)

Resuscitation:

  • Consider intubation
  • Check gas exchange (expect slight respiratory alkalosis)
  • BP currently a bit on the high side, maybe careful hydralazine to SBP 140-160

Specific therapy for cerebral venous sinus thrombosis

  • Therapeutic anticoagulation
    • Can use LMWH or UFH
    • Intracranial haemorrhage with CVT is not a contraindication to anticoagulation
    • Continued for remainder of pregnancy and usually for further 6-12 weeks postpartum
    • Aspirin – no evidence of benefit. Occasionally used as alternative if firm CI to therapeutic
      anticoagulation
  • Potential therapies include thrombolysis (systemic or catheter-directed), mechanical clot
    extraction, decompressive craniectomyAssess for underlying cause that may require specific therapy e.g.,
  • Assess for underlying cause that may require specific therapy e.g.,
    • Antiphosphoplipid syndrome
    • Sinus or parameningeal infection
  • May need an anticonvulsant; consider neurology inputPregnancy related:

Pregnancy related:

  • Involvement of obstetric service, regular CTG, ultrasound
  • ? steroids to allow for early delivery if needed
  • Shielding for X-ray and CT limit as able
  • Blood conservation given physiological anaemia of pregnancy
  • Need to keep family up to date

  • Pass rate: 67%
  • Highest mark: 8.8

Exams LITFL ACEM 700

Examination Library

CICM

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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