On the physical exam,
you wanna make sure you do a careful neurologic exam.
In those initial phases,
you wanna start thinking about your NIH stroke scale
because sometimes this can be hard to differentiate from an ischemic stroke.
You wanna calculate a GCS score.
So the GCS stands for Glasgow Coma Score
and it’s based on whether or not the patient has appropriate eye movements,
appropriate speech, and an appropriate motor exam.
The scores on that range from three
which is essentially a patient who’s unconscious with no movement,
all the way to 15, which is a normally functioning person.
And then you wanna focus on the airway and breathing.
In Emergency Medicine,
we’re always thinking about our most critically ill patients.
These patients actually may require intubation,
so they might require a ventilatory support
if they’re not able to breathe effectively,
and especially in those bleeds that affect the brainstem,
those patients may most definitely be altered
and may require these additional steps.
So always while we’re performing our neurologic exam and calculating our GCS,
we always wanna make sure that in the forefront of our brains,
we’re focusing on the airway, breathing, and circulation component.
Now, when patients present with these symptoms,
we definitely wanna make sure we’re thinking about the most dangerous things.
And one of the most dangerous things is intracerebral hemorrhage.
But we also wanna make sure
that we’re keeping our differential diagnosis a little bit broad.
That we’re making sure we’re considering
and thinking about other things that could explain
this patient’s presenting symptoms.
Hypoglycemia is one of those.
A low blood sugar can present with a whole slow of different symptoms.
So keeping that on the differential and checking a finger stick.
Migraine headaches can present with some symptoms like this as well
especially with the headache component.
Seizures can present with confusion
especially in the post ictal period, the period after the seizure.
Tumors or mass legions, and then hypertensive encephalopathy.
Hypotensive encephalopathy is different
than hypertensive vascular apathy.
Hypertensive vascular apathy
is chronically elevated blood pressure
that affects and weakens
the vessels, whereas hypertensive encephalopathy
is acute elevated blood pressure,
which results in brain edema.
This is due to end organ damage,
and this is a type of hypertensive emergency.
So for these patients, first and foremost,
check a finger stick to rule out hypoglycemia as the cause here.
Then you wanna get an emergent head CT.
This is a non-contrast head CT.
So you wanna obtain it without giving any contrast in the IV
and what this does is it helps to distinguish or differentiate
between an ischemic process and a hemorrhagic process.
Acute blood, so blood that has been there relatively recently
will appear bright white as it does on this head CT scan.
And all acute blood will appear that way
when you’re getting that non-contrast head CT.
Over a period of time, it can get a little bit trickier
because as time goes on,
that blood takes on more of a greyish appearance
and can actually really blend in with the brain tissue.
So you wanna make sure especially in those earlier scans,
you’re looking for something that’s gonna light up bright white,
similar to the color of what the bone looks like.
You wanna get coagulation studies.
Those are important for all patients
but especially for patients who are on anticoagulation medications
and you wanna try and ascertain that information
when you’re getting the history from the patient
or their family member, or the medics.
And then a toxicologic screen can sometimes be of benefit
if a patient potentially used cocaine or another sympathomimetic.