Practice Questions
Question 1.
A homeless 53 year old male is admitted to the medical ICU following cardiac arrest after he was found unresponsive in his tent. EMS reported ROSC after several rounds of epinephrine and high-quality CPR. He is intubated and stablized in the ED before transfer to the ICU. His head CT is reported as normal and has an ABG with normalized pH. In the ICU he is noted to have no motor response to any painful stimulation, unreactive pupils, no corneals and a trace cough. Vital signs are currently HR - 44, BP - 88/55, SaO2 - 98%, RR -14. The medical ICU team states that he is not overbreathing the ventilator and likely overdosed on opiates and wants you to perform brain death testing. What should you do?
A. Proceed with declaration of brain death including apnea testing
B. Await toxicology testing from urine
C. Obtain an ancillary test to confirm brain death prior to examination
D. Not proceed any further as this is not consistent with brain death
E. Rewarm the patient to 34 degrees C prior to any declaration of death
Answer - D - Not proceed any further as this is not consistent with brain death.
This patient still has a cough reflex and therefore the exam is not consistent with brain death. There are also multiple confounding factors in this case. He is currently hyopthermic, as a prerequisite for brain death is > 36 degrees C. He also has a normal head CT and therefore no identifiable cause of brain death which is also a prerequisite for testing. Ancillary testing should be reserved for when the neurologic exam cannot be trusted or when apnea testing cannot be completed.
Question 2.
A 48 year old female with HTN, HLD and tobacco abuse presents to the ED with acute onset of headache, vomiting, right facial droop, right arm and leg weakness and dysarthria. She is discovered to have a 22mL hemorrhage in her thalamus with compression of her internal capsule. A CTA of the head is also completed and identifies a "spot sign." In patients with ICH this sign is associated with?
A. Ateriovenous malformation (AVM)
B. Hematoma expansion
C. Previous intracerebral hemorrhage
D. High blood pressure at time of presentation
E. Benign calcifcation of the basal ganglia/thalamus
Answer - B - Hematoma expansion.
In a patient with acute intracerebral hemorrhage a "spot sign" signifies contrast extravasation into the hermorrhage and considered an active hemorrhage with significant risk for hematoma expansion and worse outcome. AVMs are typically seen as enlarged feeding arteries with a nidus and draining veins that demonstrate early filling. Previous hemorrhage would not be demonstratable on CTA and as brain tissues dies following injury encephalomalacia develops in the region of primary injury. High blood pressure does not have any imaging correlate and calcifications in the basal ganglia can be found in several conditions but is often confused for ICH in some patients.