# Cause of Death



## traumateam1 (Sep 22, 2008)

*Presentation*
A 64 year old woman with hypertension was admitted by her GP after complaining of right-sided weakness. Over the next couple of days her condition worsened, and four days later she appeared to suffer a serious stroke, following which she was completely unresponsive. Tests confirmed brain stem death and permission was sought to switch off her life support.

*History*
The woman had a 10-year history of hypertension. When she noticed loss of sensation and loss of power on her right side she went to her GP, who had her admitted.

*Examination *
Pulse was 80bpm, bp 154/80, normal heart sounds. 
A positive Babinsky sign was noted in her right foot. 
Moderate loss of power and sensation of limbs on right side. 
Weakness of right side of face, and dysarthria.

*Test results*
No abnormal findings on CT scan or EEG.

*Progression*
She showed no improvement of her right-sided weakness after admission to hospital. A small stroke was suspected, but no lesion could be seen on the CT scan. Four days after admission she deteriorated. Her Glasgow coma scale rating was 3. She was totally unresponsive. An MRI showed a suspected brain stem haemorrhage and a small established infarct in the left parietal lobe. 

When tests showed brain stem death, permission was sought from her family to switch off her life support, and she died 6 days after admission.



What do you think the cause of death is. I have some more information, but not a whole lot. Ask and if I know I'll tell.. if I don't know I'll just say sorry.
First person to guess gets 50 gold points 
Ready... GO!


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## Ridryder911 (Sep 22, 2008)

I think you answered that yourself. 

When tests showed *brain stem death*, permission was sought from her family to *switch off her life support*, and she died 6 days after admission. Switching off life support tends to do the trick.


R/r 911


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## traumateam1 (Sep 22, 2008)

Wrong. (Well technically correct lol) but... what caused the p/t to become this critical that the family had to decide that it would be better to turn switch off her life support?


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## traumateam1 (Sep 22, 2008)

Wow! I can't believe I forgot the list of possible causes that it gives you.
My appologies everyone!

Ok so this is the list of possible causes of death.

Atherosclerosis 
Brain stem haemorrhage 
Coma 
Duplex ureter 
Epilepsy 
Hypertension 
Ovarian cyst 
Subdural haemorrhage 
Vasculitis


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## mycrofft (Sep 22, 2008)

*Blue Cross ran out?*

What would "House, M.D." say?
Oh, yeah. "Autoimmune disorder".

Tertiary syphillis?


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## traumateam1 (Sep 22, 2008)

*House, MD*

Gotta love House! 

Sorry it's not Autoimmune or tertiary syphillis.


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## medic_charli (Sep 28, 2008)

Hmmmmmm - hx of hypertension - they don't call it the silent killer for no reason.  That sounds like the culpruit to me.


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## LucidResq (Sep 28, 2008)

Brain stem hemorrhage secondary to a basilar artery aneurysm secondary to hypertension.


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## CPG (Sep 29, 2008)

First guess is aneurysm that caused a brain bleed.


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## SmokeyBear (Sep 30, 2008)

Positive Babinski sign, a clear CT--how about poisoning? This may be reaching it but how about a Snake bite? Or some neurotoxin--spider bite?


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## knxemt1983 (Oct 1, 2008)

traumateam1 said:


> *Presentation*
> A 64 year old woman with hypertension was admitted by her GP after complaining of right-sided weakness. Over the next couple of days her condition worsened, and four days later she appeared to suffer a serious stroke, following which she was completely unresponsive. Tests confirmed brain stem death and permission was sought to switch off her life support.
> 
> *History*
> ...



I could be way off but is there any chance of spinal compromise, or some type of nerve deterioration


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## FR Wrath (Oct 31, 2008)

Wait, what's the answer?!


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## dmiracco (Nov 1, 2008)

Well  i think you pretty much answered yourself in the information you gave. 
Ultimately the patient has chronic HTN which puts her at high risk for CVA, Htn is the number one cause for intracerebral hemorrhage, however with the other sign/symptoms it would show evidence of possibly a brainstem hemmorhage.
Decrease in consciousness, dysarthia is a big sign, etc. 
Something I would ask or identify is, What is the gaze preference? Was there a report of vertigo or tinnitus? Any N/V? As these are all classic signs of a brainstem. 
You also stated that later in the progression that there was a small infarct in her left parietal lobe. So with all of the right sided deficits you may also have some involvement of a left (Dominant) hemisphere stroke. With that in mind, you definitely could have contributing factors like vasculitis and CAD secondary to a thromboembolism.
But the key here is any major embolic or hemorrhagic CVA in either hemisphere would definately show on CT scan.
Babinski sign is also pointing to a upper neuronal disease, so with the info at hand I would suggest a brainstem hemorrhage is the cause. :wacko:


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## texmat3 (Nov 15, 2008)

I want to say that it was a subdural hemorrhage (out of the choices given).  But what is the clinical difference between a subdural and a brain stem hemorrhage?  Is a brain stem hemorrhage just telling you where it is, or does it mean something extra?  I'm still in P1, so if anybody can tell me, I'd appreciate it.


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## mycrofft (Nov 15, 2008)

*Duuu-oh!*

Oh, crikey!
COD was...........
shutting off the life support.


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## SmokeyBear (Nov 15, 2008)

What is the answer? :mellow:


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## VentMedic (Nov 15, 2008)

There are many things in just assessing the brainstem for metabolic, toxic disturbances or structural damage. However, if some professionals are led astray by not exploring all the options or taking a couple of tests as the end to a differential diagnosis process, there will be a delay in treatment or other decision making pathways. A thorough neuro assessment should have been performed. The very few things listed in the scenario indicates nothings when it comes to assessment of the neuro system. It just shows there is a problem. 



> Test results
> No abnormal findings on CT scan or EEG.


 
If you are are talking brain stem injury, neither of these tests are definitive and usually just cause confusion when some take them to be as such. In this case the MRI was a defining test and should probably have been done sooner when symptoms continued without answer or other conclusive tests. There are also many bedside tests that can be done as part of a neuro assessment to lead a qualified specialist in the right direction. 



> A positive Babinsky sign was noted in her right foot.


A positive Babinski sign, either unilateral or bilateral, just indicates the need for neuroimaging such as an MRI to determine the focal area. It can be a sign for metabolic disease, hemorrhage, impaired coagulation mechanism, brain abcess, or structual disease.

While these scenarios are great to get one thinking, one should be thinking about what further physical examination is needed, lab tests, and course of treatment that would not create further complications. The very little data (not meaning to be critical) available just leads to guessing and not necessarily critical thinking. If you were to observe a physician or advanced practitioner on even how their organize their medical reports, you will note it is arranged for some form of systematic analysis. 

The format of this scenario is great but it just needed more supportive data to be a realistic scenario for medicine expecially for a complex part of the body such as the neurosystem. Unfortunately, when some do "guess", the next time they see something similar in the field, they may guess or jump to conclusions because it "sounded like" without doing the necessary steps that can rule in or rule out certain factors.

I apologize and did not want to knock any wind out of the OP's post but as you advance, you should become educated on how medical science solves difficult situations and not just rely on the few things taught in EMT(P) school or some medical terms picked up along the way without knowing their true purpose.


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## traumateam1 (Nov 15, 2008)

Sorry everyone, kinda forgot about this.
Actual answer, other than mycroffts answer of "shutting off life support" was a BRAIN STEM HAEMORRHAGE

The cause of death, as recorded on the death certificate, was listed as

1a Brain stem haemorrhage
1b Basilar artery aneurysm
2 Hypertension


In this case the MRI showed the suspected cause, which was confirmed at post mortem. Other findings related to her history of hypertension were found, such as the atheroma in different vessels, and left ventricular hypertrophy. No source of an embolus was found elsewhere in the body, but the atheromatous changes to the basilar artery would have precipitated the aneurysm (ballooning of an artery) that killed her by weakening the muscle layer (media). 

Strokes are caused either by infarction of part of the brain (where the affected area dies because its blood supply is blocked), or by bleeding into the brain (haemorrhage). Symptoms usually have a sudden onset, but may present in a progressive fashion over hours or days. Signs and symptoms vary depending on the artery in the brain that is affected, and the extent of collateral circulation.


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## mycrofft (Nov 15, 2008)

*The chads are hanging. I won!!*

Now the EMS question is....what different would we do other than not giving thrombolytics?
Gentler ride to the hospital?B)


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