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A Patients Case and

Discussion

Fiona Gallahue, M.D.


Bellevue Hospital Center

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

HEENT: NCAT eyes: PERRL bilat, EOM full

Neck: No JVD, bruits or LAD

CV:

Bradycardic, nl S1,S2 no M/R/G

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

Pt on the way to CT scan of


abdomen/pelvis when she becomes
lethargic and no longer verbal
Head CT ordered and . . .

Blood
throughout the
supracellar
cistern

Back to our patient


Neurosurgery called, pt taken to the OR
Suboccipital craniectomy/
Frontal ventriculostomy
Post-op pt regained normal mental status
Unremarkable neuro exam except for
mild right sided incoordination

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

Other risk factors


Cerebral Amyloid Angiopathy
Coagulopathy
Structural Lesions
Prior Ischemic Stroke
Drug Related
Cocaine
Amphetamines
Alcohol

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

Common causes for


hemorrhage
Hypertension
Bleeding diathesis
Trauma
Amyloid angiopathy
If bleed is in an atypical location or patient
is young, consider angiogram to rule out
aneurysm or AVM

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

Signs of Pontine Hemorrhage


Quadriparesis
Bilateral gaze paresis
Pinpoint pupils
Coma

Signs of Internal Capsule/


Thalamus Hemorrhage
Contralateral hemiparesis
Contralateral hemisensory loss
Somnolence
Decreased alertness
Anisocoria, Miosis or sluggish pupils
Normal or small pupils
Left sided bleed- Aphasia

Primary Intracerebral
Hemorrhage
External Capsule - Putamen
(35-50%)
Internal Capsule - Thalamus
(10-15%)
Central Pons (10-15%)
Cerebellum (10-30%)

External Capsule/ Putamen


Contralateral hemiparesis
Contralateral hemisensory loss
Ipsilateral conjugate eye deviation
Pupils normal or dilated
Left sided bleed- Aphasia
Right sided bleed- Left sided neglect

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

Management of Acute Strokes


Avoid D5W and excessive fluid loading
Aggressively manage hyperglycemia with
insulin
Bolus with 50% dextrose if hypoglycemia
100 mg Thiamine if alcoholic/malnourished
Supplement with oxygen
NPO if aspiration risk

Blood Pressure Management for


Acute Hemorrhagic Stroke
Systolic BP 180 mm Hg
Diastolic BP 105 mm Hg
If hypertensive prior to stroke, approximate
premorbid blood pressure

Medications recommended for


blood pressure management
SBP>230 or DBP>120
Sodium Nitroprusside 0.5-10 ug/kg/min
Nitroglycerin drip
10-20 ug/min

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

Take Home Points


Think about intracerebellar
pathology when presented with a
patient with persistent intractable
vomiting

Thank you
Multumesc