The pateint is lifted onto the cot and wisked away to the unit. She begins seizing as soon as she is loaded. There is too much going on to leave the unit medic alone back here, the patient is now displaying Cheyne-Stokes respirations, systolic hypertension, and reflex bradycardia as the ICP rises. 5 mg of Versed stops the seizures.
The jaw is clenched, so a nasal airway is inserted and aggressive ventilations are started. The bradycardia recovers and the Cheyne-Stokes respirations normalize. The hypertension is persistent.
The ride is bumpy as the EMT driving streaks toward the closest stroke center. Thankfully though, it ends quickly as the cot is pulled into the hospital and the patient offloaded. The ED physician performs RSI, and is sent for an immediate CT, and from there was sent to a waiting surgery suite for a craniotomy.
A Rose By Any Other Name…
A hemorrhagic stroke, commonly called a head bleed, is a type of stroke where a vessel is the brain or surrounding tissues ruptures and causes blood to build up and clot either in the brain itself or between the brain and the skull. It is divided into 2 types, one is the intra-axial hemorrhage which occurs inside the brain itself and the other is extra-axial hemorrhage which includes the epidural, subdural, and subarachnoid bleeds. Intracerebral bleeds account for 30-60% of all strokes.
Stroke, whether hemorrhagic or occlusive, is a serious medical emergency requiring immediate treatment. EMS usually has the first contact with people experiencing stroke symptoms, and may even be disguised as other medical problem such as unconsciousness or an unknown problem. Stroke risk is increased by pre-existing medical conditions such as hypertension, diabetes, smoking, or alcoholism.
Patients that are showing signs of increased intercranial pressure will display a set of signs and symptoms known as Cushing’s Triad. These signs and symptoms include systolic hypertension, Cheyne-Stokes respirations, and reflex bradycardia.
As you have read with this case, the primary goal of treatment is to management the symptoms on the way to definitive care. By suppressing the seizures the oxygen demand was decreased and hyperventilation decreased ICP enough to prevent herniation in transit by decreasing the CO2 in the blood stream causing cerebral vasoconstriction. Hyperventilation is recommended for TEMPORARY reduction of ICP and it is not widely used in the hospital unless the patient does not respond to other treatments and it is also not recommended in bleeds caused by trauma because it will cause reduced blood flow to the brain when the brain may already be ischemic.
Hospital treatment will include a variety of medications and possibly even surgery, as in this case, a craniotomy. A craniotomy is where a piece of the skull (bone flap) is removed and placed under the skin in the abdomen to allow the brain to expand without causing herniation while the cause of the bleed is treated.
Quick recognition, treatment, and transport can help in getting the patient back to living a normal life.