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CHAOTIC NSICU ESCAPE
Audrey Pleger
Created on November 16, 2023
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Transcript
start
ChaoticBRAIN
Escape NSICU Room
HPI: DA is a 56yo F who was speaking with her family on the phone, yelled out in pain and stopped responding. Family came to check on her and found her minimally responsive and covered in vomit. When EMS arrived, DA was hypertensive with a BP of 230/115 and bradycardic with a HR in the 20-30s. They brought her to the ED where she was intubated and taken for a head CT. CT scan demonstrates diffuse subarachnoid hemorrhage (SAH) with intraventricular extension (IVH). .
Look at the note on the fridge
PMH: Migraine headaches, Hypertension, GERD Social: Patient is a Jehovah witness
Wt: 99kg
Ht: 160 cm
Patient Info
Emergency
Urgency
Is this hypertensive urgency vs emergency?Reminder BP was 230/115
Drop to <160 SBP ASAP
Drop MAP by 20% over nect hour; then to 160 over next 6 hours
Blood pressure goals?
Labetalol IV push; esmolol, oral medications
Nicardipine gtt, clevidipine gtt, hydralazine IV push
How do we attain the goal blood pressure?
Click here if wrong answer provided
May continue once at least 3 people provide educated guesses
What other concerns do you have given some of her vitals and symptoms
HTN emergency
Patient management
Neurosurgery arrives to assess the patient. DA was intubated, bradycardic, did not withdraw to pain in any extremities, though she did have a cough and gag. Her SAH is graded as a Hung and Hess grade V and Fisher grade IV. Neurosurgery needs pharmacy help while they prepare to place an IRRAFlow device (similar to an external ventricular drain).
Patient Course Cont.
Click here if wrong answer provided
May continue once at least 2 interventions are provided
What can be done acutely in the ED? (That a pharmacist can assist with)
Click here if wrong answer provided
Click here if answered correctly
ED tx requirements
HTN emergency
Patient management
IRRAflow is successfully placed and DA is taken to the angio suite. It is found that she has a large bilobed anterior communicating artery aneurysm and they place a WEB device.
Patient course cont.
Click here if wrong answer provided
May continue once at least four people provide educated guesses
What complications is DA at risk for and how should we monitor for them?
Click here if wrong answer provided
May continue once at least four people provide educated guesses
Post-angio what medications should the patient be started on and why?
Post-angio monitoring and complications
ED tx requirements
HTN emergency
Patient Management
Day 4: Patient is following simple commands (ie. squeezing hand) Day 7: Patient neuro exam starts to decline per discussion with APP during rounds
Patient Course Cont.
Click here if wrong answer provided
Based on the above laba data, what do you think is going on? At least 2 people must take an educated guess to move on.
Patient lab data
Click here if wrong answer provided
May continue once at least three people provide educated guesses
What are treatment options for her at this time?
Click here if wrong answer provided
May continue once at least four people provide educated guesses
What other treatment(s) should continue during her stay?
Identifying and tx pt complications w standard ICU care
Post-angio monitoring and complications
ED tx requirements
HTN emergency
Patient management
You have made it out of the NSICU!!!
Congrats!
starT over?
Please try again, in order to escape the NSICU
Wrong!