A 64-year-old man is brought to the emergency department by ambulance for right-sided weakness and slurred speech that started 30 minutes ago. The wife reports that her husband said he was dizzy, and shortly after, he developed acute right arm and leg weakness and was unable to speak. Medical history includes hypertension, for which he takes amlodipine. The patient also takes an aspirin daily. Blood pressure is 225/110 mm Hg, pulse is 90/min, and respirations are 20/min. On examination, the patient is alert but aphasic with 0/5 strength in the right upper and lower extremities. Examination of the left upper and lower extremities is normal. A nicardipine infusion is started and CT scan of the head is performed. After returning from the CT scanner, the patient is minimally responsive and has developed hyperextension of all four extremities. CT scan shows a left-sided intracerebral hemorrhage with a 5-mm midline shift to the right. Which of the following is the best next step in management of this patient?

Question

A 64-year-old man is brought to the emergency department by ambulance for right-sided weakness and slurred speech that started 30 minutes ago.  The wife reports that her husband said he was dizzy, and shortly after, he developed acute right arm and leg weakness and was unable to speak.  Medical history includes hypertension, for which he takes amlodipine.  The patient also takes an aspirin daily.  Blood pressure is 225/110 mm Hg, pulse is 90/min, and respirations are 20/min.  On examination, the patient is alert but aphasic with 0/5 strength in the right upper and lower extremities.  Examination of the left upper and lower extremities is normal.  A nicardipine infusion is started and CT scan of the head is performed.  After returning from the CT scanner, the patient is minimally responsive and has developed hyperextension of all four extremities.  CT scan shows a left-sided intracerebral hemorrhage with a 5-mm midline shift to the right.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient had a stroke (eg, slurred speech, dizziness, right-sided weakness) due to hypertensive intracerebral hemorrhage. On initial presentation, he was alert and breathing spontaneously; however, his condition subsequently deteriorated, and he became unresponsive due to continued hemorrhage expansion causing brain herniation (eg, midline shift on CT scan, decerebrate posturing). In a patient, such as this one, with a rapid change in clinical status, the ABCs (Airway, Breathing, Circulation) should be reassessed. Brain herniation can rapidly lead to respiratory failure for several reasons, including the following: A decreased level of consciousness (ie, Glasgow Coma Score <8) results in an inability to protect the airway. Dysfunction of cranial nerve nuclei results in loss of specific airway protective reflexes (eg, cough, gag). Compression of respiratory centers in the brainstem causes decreased ventilatory drive, leading to hypercarbia and hypoxia. Because this patient with brain herniation has now become unresponsive and unable to protect his airway, the best next step in management is intubation and mechanical ventilation (airway and breathing of the ABCs). Subsequent management can then focus on preventing further bleeding (eg, reversing anticoagulation, controlling blood pressure) and lowering the intracranial pressure (eg, hyperventilation, osmotic agents [eg, mannitol], neurosurgical hematoma evacuation). (Choice A) Although corticosteroids are used to decrease some forms of cerebral edema (eg, vasogenic edema surrounding brain tumors), there is no evidence to support their routine use in patients with hemorrhagic stroke. (Choice B) Osmotic therapy (eg, hypertonic saline, mannitol) may be used to treat elevated intracranial pressure in patients with intracerebral hemorrhage. However, protection of the airway by intubation and restoration of breathing through mechanical ventilation take precedence. (Choice C) Although aspirin should be discontinued in the setting of intracerebral hemorrhage and platelets might be given to patients with bleeding if thrombocytopenia is present, airway protection and restoration of breathing take precedence. (Choice D) Although the patient's wishes should be determined by discussing them with the family, in a period of rapid decompensation with no previously established do not resuscitate/do not intubate status, aggressive treatment, including intubation and mechanical ventilation, should not be delayed. In addition, although mortality associated with intracerebral hemorrhage is elevated, prognostication is difficult, and aggressive management is recommended for the first 24-48 h. Educational objective: Patients with intracerebral hemorrhage can have rapid clinical deterioration, especially when brain herniation is present. When a change in clinical status occurs, the ABCs (Airway, Breathing, Circulation) should be reassessed because intubation and mechanical ventilation may be necessary (eg, airway protection).

A 64-Year-Old Man Is Brought to the Emergency Department by Ambulance