45 yom, unknown medical problem

[Handsome Robb]

I still think itsa bleed... No, but I was convinced too, especially if this was a call and I wasn't aware of a "tricky" scenario.
Subdural is the thought that comes to mind, add the meds (plavix I think) etoh, vitals and findings.


So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia

Bleed is a thought but there's only one side of the three-sided triangle that makes up Cushing's triad and some could argue there are no signs with a Hx of HTN and non-compliance with medication. Then with the second set of vitals there are no signs of increased ICP.

People generally say HTN is part of Cushing's but technically it is a widened pulse pressure by an increase in the systolic pressure. The diastolic will increase as well but not nearly as much as the systolic. The body is trying to increase cerebral perfusion pressure while attempting to keep Intracranial pressure down hence the increase in systolic rather than diastolic.

I learned something new today. Todd's paresis is a new one, or I just missed it in class. Both are viable options.

 

[FLdoc2011]

Bleed is a thought but there's only one side of the three-sided triangle that makes up Cushing's triad and some could argue there are no signs with a Hx of HTN and non-compliance with medication. Then with the second set of vitals there are no signs of increased ICP.

People generally say HTN is part of Cushing's but technically it is a widened pulse pressure by an increase in the systolic pressure. The diastolic will increase as well but not nearly as much as the systolic. The body is trying to increase cerebral perfusion pressure while attempting to keep Intracranial pressure down hence the increase in systolic rather than diastolic.

I learned something new today. Todd's paresis is a new one, or I just missed it in class. Both are viable options.

Just want to point out that you shouldn't discount a potential bleed just because you don't have Cushing's triad or other signs of ICP. We get a lot of bleeds transferred in regularly and the vast majority don't exhibit that triad, I'll see it only occasionally when SHTF and they're about to herniate. Part of this is also probably more true in older patients who naturally have some degree of cerebral atrophy and hence more space in their cranium for blood.

It's good to know the textbook presentation and all these "traids" but just remember that things can present differently in different people. Never say never.

 

[Handsome Robb]

Sorry had to run to a call.

Cerebral perfusion pressure = MAP - ICP

MAP = [(2xdiastolic) + systolic] / 3

While increasing the diastolic would increase the MAP much quicker it would also boost your ICP much faster as well.

 

[Handsome Robb]

Just want to point out that you shouldn't discount a potential bleed just because you don't have Cushing's triad or other signs of ICP. We get a lot of bleeds transferred in regularly and the vast majority don't exhibit that triad, I'll see it only occasionally when SHTF and they're about to herniate. Part of this is also probably more true in older patients who naturally have some degree of cerebral atrophy and hence more space in their cranium for blood.

It's good to know the textbook presentation and all these "traids" but just remember that things can present differently in different people. Never say never.

Agreed. Sorry, shouldn't have put that as an absolute.

 

[mycrofft]

Looking at him retrospectively with the thought of that witnessed by a "healthcare provider" seizure, this whole story changes. I think this just shows how important the history is, and how obnoxious it is when you can't get the information you need out of the people on the scene.

Didn't Gregory House MD tell us that for years?

 

[blindsideflank]

Bleed is a thought but there's only one side of the three-sided triangle that makes up Cushing's triad and some could argue there are no signs with a Hx of HTN and non-compliance with medication. Then with the second set of vitals there are no signs of increased ICP.

People generally say HTN is part of Cushing's but technically it is a widened pulse pressure by an increase in the systolic pressure. The diastolic will increase as well but not nearly as much as the systolic. The body is trying to increase cerebral perfusion pressure while attempting to keep Intracranial pressure down hence the increase in systolic rather than diastolic.

I learned something new today. Todd's paresis is a new one, or I just missed it in class. Both are viable options.

Right, that's why I raised the question about bp/map...

Also, I know this was a real Call and they can be tricky. I meant bleed was the top for the differential and I suspected that it would turn out to be something else or he wouldn't bother posting it as it would present as much of a learning opportunity.

 

[LgLuigiman]

I'm surprised that Todd's Paresis is so new to everyone. I'm going to guess most people learned about it, but just not by that name. Looking back in the textbook (assuming most of you used the big orange Emergency Care and Transportation of The Sick and Injured), I found that postictal hemiparesis is actually a key term (page 576 if we need to get specific). They just don't use the actual words "Todd's Paresis". I'm gonna bet this rings more of a bell for most people.

 

[shiroun]

I know I may be wrong on this, and you guys do have more experience with it.

However, it almost seems like he had symptoms of CO poisoning. The hot red and sweaty is what links that to me. Maybe heat stroke? What was he doing prior to sitting down and having a couple of beers? If he'd over-exerted himself, come inside and had a few beers, maybe he just had a severe orthostatic hypotension? It would explain his scrapes. He's sitting down, goes to grab a couple more beers, stands up and is out for the count. If he'd been sitting for a really long period of time, and banged his head good enough, it could potentially cause a disrupted heart rhythm, right? That would explain the loss of a pulse by first responders (that or human error, take your pick).