0 evaluări0% au considerat acest document util (0 voturi)
55 vizualizări16 pagini
1. A 67-year-old man presented with loss of consciousness and was found to have an intracranial hemorrhage on CT scan. He had a history of heart disease, heart surgery, heart failure, diabetes, hypertension and smoking.
2. Imaging showed a left frontal lobe hemorrhage with herniation and swelling. His coagulopathy from warfarin use was reversed with plasma and vitamin K. He was intubated to control swelling and underwent neurosurgery to remove the bleed.
3. Initial management focused on reversing anticoagulation, controlling blood pressure and swelling, preventing seizures, and treating comorbidities like heart failure and diabetes. The patient was referred
1. A 67-year-old man presented with loss of consciousness and was found to have an intracranial hemorrhage on CT scan. He had a history of heart disease, heart surgery, heart failure, diabetes, hypertension and smoking.
2. Imaging showed a left frontal lobe hemorrhage with herniation and swelling. His coagulopathy from warfarin use was reversed with plasma and vitamin K. He was intubated to control swelling and underwent neurosurgery to remove the bleed.
3. Initial management focused on reversing anticoagulation, controlling blood pressure and swelling, preventing seizures, and treating comorbidities like heart failure and diabetes. The patient was referred
1. A 67-year-old man presented with loss of consciousness and was found to have an intracranial hemorrhage on CT scan. He had a history of heart disease, heart surgery, heart failure, diabetes, hypertension and smoking.
2. Imaging showed a left frontal lobe hemorrhage with herniation and swelling. His coagulopathy from warfarin use was reversed with plasma and vitamin K. He was intubated to control swelling and underwent neurosurgery to remove the bleed.
3. Initial management focused on reversing anticoagulation, controlling blood pressure and swelling, preventing seizures, and treating comorbidities like heart failure and diabetes. The patient was referred
RSUP Dr. Sardjito UGM-NUS elective Anesthesia emergency Initial presentation - Mr S, 67-yo Indonesian man presented on 16 May 1:00pm - Loss of consciousness - At outpatient clinic for appointment → Fell down - Brought immediately to ER - Past Medical History - Ischemic heart disease - Previous CABG (midline sternotomy) - On warfarin - Congestive cardiac failure (EF 30%) - Diabetes mellitus - Hypertension - Smoker Primary survey Assessment Management
Airway Clear - No noisy breathing / stridor
Breathing Tachypnoeic (21 bpm) Nasal prong → NRM
Use of accessory muscles BGA Oxygen saturation 94% Chest XR
Pupils 3/3 mm; equal and reactive to light Maintain airway Capillary glucose (normal) Neurosurgical consult NG tube + Nil by mouth
Environment & Coffee-ground vomitus Lenoprazole + NG aspiration
Exposure No other trauma Secondary survey Head GCS 7 No head injury No maxillofacial trauma
Neck No trauma, deformities or neck injury
Chest Midline sternotomy scar
Heart: S1S2, no murmurs Lungs: Bilateral breath sounds positive No trauma
Abdomen Soft, non-tender; no guarding/rebound
Bowel sounds present No trauma
Musculoskeletal No trauma, deformities, open fractures
Neurological Babinski +ve, hypertonia
Myoclonic jerking History - Fall Pre Walking to clinic
During Loss of consciousness; no seizure
No head injury
Post Did not regain consciousness
Myoclonic jerks
- Left sided generalized weakness
- Gradual onset over 1-week; progressively worse - No focal neurological signs (vision loss, facial drooping, receptive/expressive aphasia, balance) - No vomiting, headache - No previous seizure / epilepsy - No previous stroke - No fever, photophobia, neck stiffness - No loss of weight/loss of appetite History - Past Medical History
- Narrowing of left lateral ventricle - Subfalcine hernia (1.37cm) - Uncal herniation to the left - Increasing ventricle volume to 91cc 2. SAH in bilateral frontal lobes and temporal lobes, with the involvement of left lateral sulcus 3. SDH of falx cerebri anterior 4. Oedema cerebri Investigations Imaging (Head CT)
1. Left frontal lobe ICH with perifocal oedema
- Narrowing of left lateral ventricle - Subfalcine hernia (1.37cm) - Uncal herniation to the left - Increasing ventricle volume to 91cc 2. SAH in bilateral frontal lobes and temporal lobes, with the involvement of left lateral sulcus 3. SDH of falx cerebri anterior 4. Oedema cerebri Investigations Biochemical test FBC Liver Renal Blood gas Coagulation Blood panel panel with analysis panel glucose elctrolytes
6. Supportive care Antibiotic prophylaxis → Ceftriaxone
Replacement fluids → 0.9% normal saline Definitive management - Neurosurgery referral for removal of bleed Progress 1. Neurosurgical referral ○ Patient not for immediate surgery ○ INR too high → bleeding risk ○ Suggest: correct coagulopathy 2. Anesthesia ○ Rapid Sequence Intubation with controlled ventilation i. Fentanyl 200mcg ii. Rocuronium 50mg ○ Sedation i. Propofol continuous infusion 25-100mg/kg/min ○ Analgesia Thank you