You are asked to admit a 46-year-old male who has just been intubated in the Emergency Department (ED) after collapsing from a brain stem stroke, two hours earlier. His Glasgow Coma Scale (GCS) prior to intubation was 6.
Outline your management strategy for him for the first 24 hours.
Resuscitation, definitive and supportive treatment. 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
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.
Investigation for underlying cause / risk factors and treatment as appropriate.
This question is virtually identical to Question 13 from the second paper of 2011, with the exception of the college this time specifying that the collapse occurred two hours ago. The answer to Question 13 is therefore reproduced below with minimal modification.
The college is asking what one might do with a brainstem stroke; in order to pass the candidate needs to
A detailed discussion of the definitive management options in acute stroke is available elsewhere.
Supportive management of acute stroke is also covered in a summary article.
If one were to summarise in brief the approach to management here, it would resemble this:
*It should be pointed out that in a previous incarnation of this question (2011), the college suggested the use of a heparin infusion. This strategy has now fallen out of favour, given that it seems to kill people. Certainly, the 2007 AHA guidelines were not in favour of its use. In spite of this, the heparin anachronism has also been repeated in the college answer to this question.
Oh's Intensive Care manual: Chapter 51 (pp. 568) Acute cerebrovascular complications by Bernard Riley and Thearina de Beer. This chapter of Oh's has the distinction of having very few tables in it - there are only two, for an extremely long block of text.
The Internet Stroke Centre has an excellent summary of stroke syndromes.
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