Author: Hind Goriel / Editor: Sarah Edwards / Codes: ACCS LO 2, NeuC12, NeuP1, NeuP2, NeuP8, SLO1 / Published: 12/08/2022
A 21-year-old female patient presents to the Emergency Department (ED) in the morning. She was brought in by her family after they were unable to wake her up. The family stated that their daughter was unwell for the last 3-days complaining mainly of headache, neck pain and dizziness. She has been to the local outpatient clinic and was diagnosed with tension headache for which she was given paracetamol but not much response noticed. There was no history of trauma or fall.
She has no past medical history. She is a non-smoker and does not drink any alcohol.
Upon arrival to the ED, the patient was unresponsive. Her blood pressure was 110/68 mmHg, heart rate 93 beats per minute, temperature 36.7°C and oxygen saturation 100% in air. The pupils were equal and are 4 mm size, round and reactive to light; the oropharynx was clear; and the neck was flexible. Precordial examination showed audible regular heart sounds with no murmur, the lungs were clear bilaterally with good air-entry, and the abdomen was not distended, soft and not tender to palpation. No lesions noted on exposure and peripheral pulses were positive. The Glasgow Coma Scale (GCS) score was 7 with eyes closed, nonverbal with withdrawal from pain.
The gag and corneal reflexes were normal. Hyper-reflexion noted in all body tendons. A CT-head without contrast was negative for bleeding or ischemia. Her full set of blood tests showed no abnormality.
Venous blood gas showed pH 7.41, pCO2 5.1, pO2 9.2 and bicarbonate 20.1 mEq/L. Glucose was 6.5 mmol/L.
ECG showed normal sinus rhythm with no evidence of ischemic changes or conduction abnormality.
Module Content
Primary Headache
Acute, severe headache is a common symptom of patients presenting to the emergency department. In 90% of cases, the cause will be one of the primary headache syndromes.
Non-traumatic Subarachnoid Haemorrhage
This session describes the management of presentations of non-traumatic subarachnoid haemorrhage in the ED.
Sudden Visual Loss
Sudden visual loss is a presentation one should expect and be prepared to see, as an emergency physician.
9 Comments
Interesting article, although, in reality I’m not sure events would unfold as the MCQ suggests. Firstly, I can imagine a high degree of reluctance to intubate a patient who is maintaining their own airway and has a good motor score. Particularly as it removes the ability to perform serial neurological assessments. Secondly, in the presence of a normal non-contrast CT head, I imagine the patient would be admitted for MRI, particularly in the absence of lateralising signs.
Thanks for your comment.
The motor power will weaken over time giving the evidence of low GCS which will put her airways at risk (airway compromise is inevitable in this case) and these patients will end up in ITU/Intubation and MV. If you notice that this patient was not intubated prior to the initial non-contrast CT scan and there was time to assess the neurological status of the patient.
Next steps would be CTA (Alternatives are MRI and MRA scans) as mentioned in the discussion under Q.3 but for the sake of time, CTA is more appropriate in the emergency setting but it also depends on availability of the scan as in many tertiary hospitals CT scans are more readily available than MRIs particularly in (OOH).
Good module, though if considering dissection perhaps it would be reasonable to do an aortogram at time of CTA?
That’s right. Dissection can be considered as a potential etiology as mentioned in the discussion under Q.2 ‘Atherosclerosis of the basilar artery itself may also be responsible for BAO or may propagate from a vertebral artery thrombus or dissection’.
Really good case. Learned something.
Thank you 🙂
This is an interesting case- with senior support some may not have initially intubated due to intact pharyngeal reflexes, but decided later with the diagnosis or failure to improve. Arch aortogram would also be considered with the availability of stroke Thrombectomy.
good case
Nice one