Professional Documents
Culture Documents
Discussion
The Case
65 y.o. female brought in by ambulance from
public library for sudden onset of profuse
repetitive vomiting and weakness.
Pt reports I feel sick and vomiting q2-3
minutes.
Denies HA,SOB,CP, Abd pain, unusual
dining experiences, ill contacts, drugs or
EtOH
PMH:
1) Angina
2) CABG 2 vessel 10 years
ago
3) HTN
PSH: Lives in an assisted care facility
MEDS: 1) Procardia prn
2) NTG prn
NKDA
Physical Exam
Ill appearing female, looking older than
stated age, cool clammy, diaphoretic.
BP: 140/71 P: 65
RR: 22
T: 98 rectal
CV:
Chest:
Abd:
Rectal:
Ext:
Neuro:
Coarse BS bilat,
crackles throughout right,
crackles one- third left side,
no W/R
S/NT/ND, good BS, no masses,
no HSM
Brown stool, guaiac neg, good
tone
Cool,clammy, no
clubbing /cyanosis /edema
A&O x 3. CN intact.
Pt non-cooperative with motor,
LABS
CBC: WBC 10, HCT 39, PLT 228
normal differential
Electrolytes unremarkable
Hepatic panel/ Amylase/ Lipase /
Ammonia NORMAL
CPK 40 MB 1.1
ABG on 100% O2:
7.41/44/292/27/+3/98%
Lactate 2.0
Radiologic Studies
CXR: Poor inspiration, poor
quality, no obvious infiltrates or
effusions
AXR: no air-fluid levels, no
distended loops, normal x-ray
Our Differential
- Cardiac
- Metabolic/ Endocrine
- Gastrointestinal
- Neurologic
- Vascular
- Osthostatic Hypotension
- Psychogenic
Cardiac Causes of
Nausea/Vomiting
Acute myocardial infarction
Arrythmias
Metabolic/Endocrine Causes
Diabetes mellitus with hyper/hypoglycemia
Volume depletion
Azotemia (high ammonia)
Uremia
Toxic Ingestion/ Alcohol ingestion
Gastrointestinal
Viral gastroenteritis
GI bleed/ Gastric irritation
Surgical emergencies/
Irritation of hollow viscus
Appendicitis
Cholecystitis
Mesenteric Ischemia
Obstruction
Neurologic
Increased Intracranial Pressure
Mass lesion
Bleed
Pseudotumor cerebri
Ischemic stroke
Vestibular vertigo
Vascular
Carotid artery stenosis
Vertebral basilar insufficiency
Thrombosis to circle of Willis
Orthostatic Hypotension
Medication interaction
Prolonged bed rest
Volume depletion
Anemia
Neurogenic disorders/
Autonomic neuropathy
Blood
throughout the
supracellar
cistern
Intracerebral Hemorrhage
Intracerebral bleeds occur 12 per
100,000 people in the U.S.
10%-15% of all strokes
Men 50% more common than women
African-Americans rate twice that of
caucasians
Strong association with HTN
RISK FACTORS
Smoking
Primary Intracerebral
Hemorrhage
External Capsule Putamen (35-50%)
Internal Capsule Thalamus (10-15%)
Central Pons (10-15%)
Cerebellum (10-30%)
Follow Up Rounds
Fiona Gallahue M.D.
Bellevue Hospital Center
Prognosis
Excellent if caught early
Most achieve good status - complete recovery
Mortality is higher than ischemic CVA
30-84% vs 15-30%
Worse mortality associated with older patients
and large hemorrhage size
Prognosis directly correlates to amount of
deficit at time of diagnosis
Cerebellar Hemorrhage
Presentation
Consciousness usually preserved early
stages
Occipital HA common
Unsteady gait, clumsiness common
Seizures uncommon
Numbness/Weakness/Vomiting
Pupils small
Cranial nerve abnormalities
Treatment of cerebellar
hemorrhage
Neurosurgical Consult immediately!!!
ABCs
Mannitol and Hyperventilation as needed
ICU observation and repeat CT scan 24-48
hours
Surgical evacuation if:
Patient clinically deteriorating
Large hematoma
Hematoma enlargement
Primary Intracerebral
Hemorrhage
External Capsule Putamen (35-50%)
Internal Capsule Thalamus (10-15%)
Central Pons (10-15%)
Cerebellum (10-30%)
Follow Up Rounds
Fiona Gallahue M.D.
Bellevue Hospital Center
Primary Intracerebral
Hemorrhage
External Capsule - Putamen
(35-50%)
Internal Capsule - Thalamus
(10-15%)
Central Pons (10-15%)
Cerebellum (10-30%)
Management of nontraumatic
noncerebellar hemorrhages
Investigate cause of bleed
Airway, Breathing and Circulation
Control of Hypertension
Control of ICP if patient deteriorates
Generally, no surgery required unless
sizable lobar hemorrhage or neurological
deterioration noted
SBP:180-230 or DBP:106-120
Labetolol:10 mg bolus q10-20 min,max 300mg
ALTERNATIVES:
Sodium Nitroprusside 0.5-10 ug/kg/min
Enalaprilat 0.625-1.25 mg IV, max 5mg/kg q6h
Nicardipine 20-40 mg po q8h
Thank you
Multumesc