Question Of The Day #44

question of the day

Which of the following is the most appropriate next investigation to confirm this patient’s diagnosis?

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The information provided indicates that the patient’s headache was maximal at onset, severe, associated with vomiting, and led to a deteriorating mental status ultimately requiring intubation.  This history is very concerning for intracranial bleeding, especially subarachnoid hemorrhage (SAH).  The majority of atraumatic SAHs are caused by the rupture of a saccular aneurysm.  This causes the leakage of blood into the subarachnoid space.  Symptoms of a SAH are sudden onset headache that is maximal intensity at onset (“thunderclap headache”), syncope, vomiting, seizures, and any neurological deficits.  Risk factors for SAH are age over 50years-old, family history of SAH, alcohol abuse, tobacco smoking, Marfan Syndrome, Ehlers-Danlos Syndrome, and Polycystic Kidney Disease.  Diagnosis of SAH takes into account the patient’s history, physical exam, and risk factors. 

Patients that arrive in the Emergency Department under 6hours since symptom onset should initially get a noncontrast CT scan of the head (Choice D).  When a noncontrast head CT is performed in this time window, its sensitivity reaches 98-100%.  Noncontrast head CTs performed within the first 24hrs since headache onset have a sensitivity of about 90%.  Patients with signs and symptoms concerning for SAH who have a negative CT head should get a lumbar puncture (Choice A) to evaluate for xanthochromia.  This is especially important if the patient’s symptoms have been for over 6 hours.  A 12-lead EKG (Choice B) can show ST and T wave changes, but an EKG alone cannot be used to make a diagnosis of SAH.  A brain MRI (Choice C) can make the diagnosis of SAH, but a CT scan would be preferred due to greater CT scan accessibility, cost, and the shorter time of this imaging test.  The best next investigation would be a noncontrast CT of the head (Choice D).

Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #44," in International Emergency Medicine Education Project, July 2, 2021, https://iem-student.org/2021/07/02/question-of-the-day-44/, date accessed: December 5, 2022

Epidural Hematoma

epidural hematoma

Authors: Kilalo Maeli Mjema, Emergency Physician and Mugisha Clement, Neurosurgeon.

Case Presentation

A 34 years old male sustained a traumatic brain injury following a motor vehicle accident 3 hours before presentation to ED. BP: 117/69mmHg. HR: 84, RR: 18, SPO2: 99% in room air, T: 36.9.

Primary Survey

Airway: patent and protected
Breathing: bilateral equal air entry
Circulation: warm extremities, 1 second capillary refill time
Disability: alert and oriented, pupils 4mm bilaterally equally reactive to light, RBG 5.6 mmol/L
Exposure: raccoon right eye, bruises on the forehead and upper limbs

SAMPLE History

Signs and symptoms: mostly chest pain than the headache, nausea
Allergies: no known allergies
Medication: had received tramadol, dexamethasone, tetanus toxoid and some intravenous fluids before being referred to our facility
Past medical history: no known comorbid or any significant history
Event: sustained motor vehicle accident as a motorcycle driver with no helmet on 3 hours prior presentation, associated with a 20 minutes loss of consciousness. Attended at another facility where he regained his full consciousness, wounds dressed, medication given as above, E-FAST negative and CT imaging done. He remained conscious throughout and was transferred for neurosurgical observation and interventions.

Neuro-observation and continuous monitoring were planned. Blood samples sent for CBC, PT, aPTT, blood type and crossmatch. The neurosurgical review was done, and the patient was to be kept inpatient for close neurosurgical observation and interventions as needed.

Patient progress while still in the ED

In the course of stay in the ED, the patient started to vomit, became drowsier overtime, was moving mostly the right side of his limbs. The right pupil was 6-7mm non-reactive to light and GCS dropped to E1M4(Rt)V2

Vitals

BP 133/79 mmHg HR 39-45 bpm RR 14 rpm SPO2 99% in room air.

The patient was emergently transferred for repeat imaging and prepared for emergency craniotomy and hematoma evacuation. Theatre was informed and ready to receive the patient.

Rapid sequence induction and intubation 

  • Patient pre-oxygenated
  • Induction with iv ketamine 2mg/kg (weight 75kg)
  • Paralyzed with iv suxamethonium 100mg 
  • Intubated by sized 8 cuffed ETT

Mannitol 20g iv infusion was given over 10 minutes.

Intraoperative Findings and Progress

Right frontotemporoparietal craniotomy was done. Approximately 100 mls of hematoma because of spurting bleeding from the medial meningeal artery was found.  No other obvious identifiable bleeding was seen. Hemostasis was achieved and closed in layers with a drain. The patient had a complete neuro improvement, extubated at day 5 and discharged 9th day.

Clinical Pearls

  • The incidence of epidural hematoma is highest among adolescents and young adults
  • Most cases are a result of head trauma by traffic accidents, falls or assaults
  • Most commonly due to middle meningeal arterial bleed
  • Epidural hematoma does not cross suture margins but crosses dural attachments as a convex lens shaped appearance
  • Lucid intervals are seen in patients
  • Watch for raised intracranial pressure; ipsilateral dilated pupil, Cushing reflex, altered mentation, vomiting
  • Glucocorticoids have no role in reducing cerebral edema in traumatic brain injury
  • In the presence of epidural hematoma with the feature of herniation, mannitol can be given with caution that craniotomy and evacuation is going to be done immediately
  • Ketamine in RSII can still be considered in traumatic brain injury where blood pressures are not raised

Clinical Pearls

In the context of non-operative management, properly monitoring neurologic status and progress is the key factor to recognise early need of emergency medical intervention, re-imaging and neurosurgery.   

References and Further Reading

Cite this article as: Kilalo Mjema, "Epidural Hematoma," in International Emergency Medicine Education Project, January 15, 2020, https://iem-student.org/2020/01/15/epidural-hematoma-2/, date accessed: December 5, 2022

From Experts To Our Students! – GIB

Sudden Severe Headache

665-  SAH

In case you didn’t encounter a sudden severe headache today!

A 46-year-old female patient presented with severe headache. BP: 178/88 mmHg, HR: 103 bpm, RR: 22/min, T: 37, SpO2: 98% in room air. She has no history of disease. She is unconscious (GCS E1, V3, M4). No obvious lateralized motor deficit. Bedside gluco-check is normal. You intubated her to secure airway and send her to the CT (above image). What is your next action?

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