Analysis of Emergencies Case Study – 5. “Headache in a 72 year-old woman”

Analysis of Neurological Emergencies Case Study - 5. "Headache in a 72 year-old woman"

Answer 1 out of 5

The patient presents with what appears to be a mechanical fall and a frontal hematoma. She has some mild mental status changes, although it is not clear if these changes are new or due to her chronic dementia.

What is the MOST APPROPRIATE next step to take?

Correct Choices:
c.	Apply a cervical collar to immobilize the patient’s cervical spine.
The initial stabilization of this patient must include cervical spine immobilization and subsequent cervical spine imaging. Most emergency medicine physicians utilize one of two algorithms for determining which patients require cervical spine immobilization and imaging. The clinical decision pathways of both of these algortithms - the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-Spine Rule (CCR) - are presented subsequently. By either algorithm, however, this patient needs cervical spine immobilization and cervical imaging.
Incorrect Choices:
a.	Determine oxygen saturation via pulse oximetry.
Although determination of the patient’s oxygen saturation via pulse oximetry is a reasonable intervention in this case, a more urgent intervention is required. There is a better answer.
b.	Obtain an electrocardiogram.
Although the patient denies any chest pain or shortness of breath, her nausea and history of coronary artery disease raise the possibility of ischemic heart disease. Although an ECG is a reasonable intervention, however, a more urgent intervention is required. There is a better answer.
d.	Obtain a stat portable chest x-ray.
There is no clear indication for a chest x-ray in this patient, and a more urgent intervention that is required. There is a better answer.

 

Answer 2 out of 5

What is the BEST description of the finding(s) on this head CT?

 

Correct Choices:
a.	Acute subdural hematoma
The findings on this head CT are consistent with an acute subdural hematoma (a full discussion of acute, subacute and chronic subdural hematomas follows on the next slide.)
Incorrect Choices:
b.	Subacute subdural hematoma
The findings on this head CT are consistent with an acute subdural hematoma (a full discussion of acute, subacute and chronic subdural hematomas follows on the next slide.)
c.	Chronic subdural hematoma
The findings on this head CT are consistent with an acute subdural hematoma (a full discussion of acute, subacute and chronic subdural hematomas follows on the next slide.)

Answer 3 out of 5

The patient is on warfarin and is clearly coagulopathic by laboratory testing. She also has a potentially life-threatening hemorrhage from a non-compressible source.

What is the ideal treatment of this patient’s coagulopathy?

Correct Choices:
d.	All of the above in combination
This patient has a life-threatening hemorrhage, and treatment with all three of these agents is appropriate.
Incorrect Choices:
a.	Prothrombin complex concentrate
Although infusion of prothrombin complex concentrate is an appropriate intervention in this patient, it may not be sufficient when used in isolation. There is a better answer.
b.	Fresh Frozen Plasma (FFP)
Although fresh frozen plasma is an integral part of the reversal of this patient’s coagulopathy, it will take an hour or more to infuse enough FFP to do this. There is a better answer.
c.	Vitamin K
Although Vitamin K should be administered to this patient, it will take several hours before Vitamin K alone could reverse this patient’s coagulopathy. There is a better answer.

Answer 4 out of 5

Patients who are anticoagulated with warfarin need reversal of this anticoagulation in the event of life or limb threatening bleeding from a non-compressible source, such as an intracranial hemorrhage. Which of the following statements regarding the administration of various drugs and/or blood products to patients is TRUE?

Correct Choices:
d.	Prothrombin complex concentrate, FFP, and Vitamin K should all be given to patients with life-or limb-threatening bleeding from a non-compressible source.
Patients such as these need immediate and long-lasting reversal of their anticoagulation. A logical treatment plan starts with the administration of prothrombin complex concentrates if available for immediate reversal. Infusion of FFP insures that the patient does not re-develop a coagulopathy as the prothrombin complex concentrate are consumed or degraded. Finally, vitamin K is given so that the patient may begin regenerating their own clotting factors.
Incorrect Choices:
a.	Fresh frozen plasma (FFP) should be administered as soon as possible; prothrombin complex concentrate is indicated only if the blood bank states that their will be a delay in obtaining the FFP.
Although FFP should be administered, it may take an hour or more to adequately reverse the effects of the patient’s warfarin. There is a better answer.
b.	Prothrombin complex concentrate is adequate monotherapy in patients with an INR < 10.0.
Although prothrombin complex concentrate can and should be given to patients such as this when it is available, it is not necessarily effective as monotherapy. There is a better answer.
c.	Vitamin K is adequate monotherapy in patients with an INR < 5.0.
Vitamin K will reverse the coagulopathy, but on the order of 12-24 hours after administration. There is a better answer.

Answer 5 out of 5

A 59 year-old man is receiving enoxaparin (Lovenox? for the outpatient treatment of a deep venous thrombosis. He has a history of melanoma with known metastases to the brain. He presents to the ED with a headache, and a stat CT of the head is obtained. A representative image of the head CT is shown above (Figure 04, click to enlarge). The patient’s last dose of LMWH was 60 mg subcutaneously, 5 hours prior to arrival. You check a package insert for enoxaparin and determine that there are 100 anti-Factor Xa units per milligram of enoxaparin.

Which of the following is the MOST APPROPRIATE treatment of this patient?

Correct Choices:
c.	Administer protamine sulfate, 60 mg IV; may administer a repeat dose of 30 mg IV if clinical deterioration suggests ongoing bleeding.
Protamine sulfate is the best agent to reverse the anticoagulant effects of low molecular weight heparin compounds. The appropriate treatment is 1 mg of protamine for every 100 anti-Factor Xa units of the LMWH compound. According to the package insert, enoxaparin contains 100 anti-Factor Xa units per milligram; an appropriate protamine dose for a patient who received the LMWH within the last 8 hours is therefore 1 mg protamine per 1 mg enoxaparin. In this patient, that would be 60 mg. If bleeding continues, a repeat dose of 0.5 mg protamine per mg of enoxaparin (30 mg) would be appropriate.
Incorrect Choices:
a.	Administer vitamin K, 10 mg IV.
The patient’s coagulopathy is due to the activation of antithrombin III, not a deficiency of vitamin K dependent clotting factors. The administration of vitamin K is unlikely to be of any benefit. There is a better answer.
b.	Administer FFP, 4 units over one hour.
The infusion of additional clotting factors is not the appropriate way to reverse a heparin-associated coagulopathy. The patient’s coagulopathy is due to the activation of anti-thrombin III, not a deficiency of clotting factors. There is a better answer.
d.	Administer protamine sulfate, 6 mg IV; may administer a repeat dose of 30 mg IV if clinical deterioration suggests ongoing bleeding.
Although protamine is the correct drug to use, this is not the appropriate dose. There is a better answer.