From the Guidelines
The rapid response leader should immediately assess the patient's vital signs and level of consciousness, and determine if resuscitation efforts align with the patient's palliative care goals, considering the patient's previous palliation for an intracerebral hemorrhage and current unresponsive state. Given the patient's condition, the leader should check for a pulse and breathing, establish if a DNR/DNI order exists, and consult the palliative care documentation 1. If resuscitation is not contraindicated, the team should move the patient to a flat surface, establish IV access, provide supplemental oxygen, and monitor cardiac rhythm. The focus may shift to comfort measures rather than aggressive interventions, depending on the documented care plan and family wishes, as the patient is receiving palliative care.
The patient's age and previous condition should be taken into consideration when deciding the course of action, and the leader should prioritize the patient's quality of life and minimize any potential harm 1. The cramped bathroom setting presents logistical challenges for initial assessment and intervention, so moving the patient safely to an appropriate location is a priority. Throughout this process, the leader should communicate clearly with the team, assign roles, and contact the primary physician. If the patient is stable but unresponsive, they should be transferred to a higher level of care for further evaluation, and the leader should also ensure the family is notified promptly.
Key considerations in this scenario include:
- Assessing the patient's vital signs and level of consciousness
- Determining if resuscitation efforts align with the patient's palliative care goals
- Checking for a DNR/DNI order and consulting the palliative care documentation
- Providing comfort measures and minimizing harm
- Communicating clearly with the team and family
- Transferring the patient to a higher level of care if necessary, as recommended by recent guidelines 1.
From the Research
Appropriate Response for a 90-year-old Patient
The patient in question is a 90-year-old who was previously palliated for an intracerebral hemorrhage and was found unresponsive while on the toilet 24 hours after deep palliation. Given this scenario, the appropriate response would involve several key considerations:
- Ensuring an adequate airway, as emphasized in the management of intracerebral hemorrhage 2
- Proper diagnosis and early management of issues such as blood pressure, coagulopathy reversal, and potential surgical hematoma evacuation if appropriate 3, 2
- Considering the patient's age and previous palliation, the focus might be more on supportive care and management of complications rather than aggressive interventions
Management of Intracerebral Hemorrhage
Key aspects of managing intracerebral hemorrhage include:
- Blood pressure management: Intensive lowering of systolic blood pressure to <140 mmHg is proven safe 3
- Coagulopathy reversal: Especially if the patient is on antiplatelet therapy or has a coagulopathy 3, 4
- Intracranial pressure control: Using measures such as ventriculostomy for patients with severe intraventricular hemorrhage or hydrocephalus 3, 4
- Consideration of surgical intervention: For patients with large cerebellar or temporal ICH, or those with significant mass effect and a deteriorating neurological exam 3, 4
Specific Considerations for This Patient
Given the patient's unresponsive state and recent history of deep palliation for intracerebral hemorrhage:
- The immediate priority would be to ensure airway protection and assess the need for ventilatory support 2
- Evaluation for potential causes of the unresponsive state, such as re-bleeding, hydrocephalus, or severe edema, would be crucial 4, 5
- Management strategies might include osmotherapy with mannitol or hypertonic saline for elevated intracranial pressure, as these have been shown to be effective in reducing ICP 6