Option 2: Hemorrhagic stroke

The patient has obvious aphasia and right hemiparesis. The nurse tells you this is worse than when he paged you 5 minutes ago. At that time, the patient reported severe headache and tingling in the right arm and leg.

You ask the nurse to call the front desk and activate a stroke code. As you place continuous cardiac monitors on the patient, he starts to gasp and develops inspiratory stridor. You lay the patient back and provide jaw lift, which relieves the stridor and gasping, but voluminous secretions start coming out of his mouth. Initial vital signs are heart rate 120 beats/minute, blood pressure 240/120 mm Hg, respiratory rate 24 breaths/minute, and SpO₂ 93%.

Question: What is your next step?

Make your choice, then click on the explanation bubble to reveal the answer.

• Proceed with a focused examination since the airway is open.
• Leave the blood pressure alone until an ischemic stroke is ruled out with a head CT.
• Obtain more history for the neurologist.
• Call the airway response team for airway support.
• Order a head CT or MRI.

Hemorrhagic strokes can progress rapidly and cause life-threatening increases in intracranial pressure. Be vigilant for patient deterioration.

Intubation of patients with increased ICP carries high risks; the most experienced provider available should perform the intubation.

The airway response team has arrived and is taking responsibility for intubation. The nurse informs you that the patient was begun on rivaroxaban 2 days ago for a lower extremity embolism caused by atrial fibrillation. Repeat vital signs are heart rate 120 beats/minute, blood pressure 248/124 mm Hg, respiratory rate 24 breaths/minute, and SpO₂ 99%.

Question: What should you do next?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Initiate positive-pressure ventilation with neuroprotective measures.
• Lower the blood pressure.
• Maintain normoglycemia.
• Obtain diagnostics.
• Maintain normothermia.

That's right—all of the above!

The patient goes to radiology and is brought back quickly, but the neurologist is still 5 minutes away. While the following are typically not your responsibility, it doesn’t hurt to think ahead.

Question: What else should be considered in this patient?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Anticoagulation reversal
• Platelet transfusion
• ICP monitoring

That's right—all of the above!

The main utility of early neuroimaging is to differentiate an acute intracranial bleed from an ischemic stroke. Findings consistent with hemorrhage are much less nuanced than those of ischemia—learn to look for them.

Head CT interpretation

Test your eyes on the following images. Identify the pertinent findings, then apply the AMBOSS overlay to check.

Treating a patient with an intracerebral hemorrhage is challenging. Decisions must be made quickly despite many overlapping considerations. Review the following to understand the nuances of managing this complicated condition.

• Intracerebral hemorrhage
• Anticoagulant reversal
• Elevated intracranial pressure and brain herniation

If you haven't explored the other scenario yet, jump over to “Option 1: Ischemic stroke.” You can also return to the main module; see “Signal lost wrap-up.”