I came across this clinical scenario and found it interesting so I am sharing it here. Its a perfect example of how neurosurgical emergencies are all about quick thinking and sharp judgement where every detail matters.
In what order do you prioritize these emergency patients for evaluation -
A 70 yr old non verbal patient with a fixed dilated right pupil unresponsive to light
A 19 yr old, post motor cycle accident, complaining of neck pain with normal CT scan
A 46 yr old with acute back pain and newly developed bladder incontinence
A 53 yr old on blood thinners presenting with sudden severe headache and vomiting
Which patient would you prioritize first and what is your reasoning behind it
I’m divided between the first patient who is 70 yrs old with right fixed dilated pupil and last patient, 53 yrs old with severe headache and vomiting. In the first case, the differential diagnosis include stroke, aneurysm, brain hemorrhage or brain tumor ; all of which indicate medical emergency. In the last case, patient is on blood thinners and symptoms of severe headache and vomiting indicate internal bleeding which should be treated urgently. Given the life expectancy of both the patients, I think 53 yrs old patient should be prioritized.
Actually ,based on life expectancy and actual symptoms I’ll go with the
53 year old patient with complaints of severe headache and vomiting who on blood thinners- may be a case of ICH need for immeduate imaging followed by management
Then ,the 70 year old patient with right dilated and fixed pupil - may be a case of herniation or compression to occulomotor nerve
Then that 46 year old patient with lower back pain and bladder incontinence - possibly a cauda equina syndrome
And then the 17 year old patient with c/o neck pain secondary to motor cycle accident( however I will immobilize his neck ast first )
What a fantastic and thought-provoking case! Prioritizing the 70-year-old with a fixed, dilated pupil in this situation is crucial because it may indicate a brain herniation, a potentially fatal situation that requires prompt medical attention. The 53-year-old who was taking blood thinners and had a really bad headache—likely an intracranial bleed—would come next. Following this, the 46-year-old with bladder incontinence may have cauda equina. Finally, the 19-year-old whose CT scan was normal but who had neck pain. Excellent example of crucial decision-making!
This case presents a tough situation where a doctor must choose which of four patients to treat first — a real-life example of medical triage. The patient most in danger seems to be the 53-year-old on blood thinners with a sudden headache and vomiting, which could mean serious brain bleeding. The 70-year-old with a dilated pupil might be next, as it could signal a brain herniation. The 46-year-old with bladder issues could have spinal cord compression, needing urgent care to avoid permanent damage. Lastly, the 19-year-old with neck pain but a normal scan is stable for now. These choices require tough calls based on urgency and survival chances.
53 year old first because suddenly severe headache and vomiting often is a sign of hemorrhage and takes priority. We can also include the age factor here.
I would say 53 year old on blood thinners presenting severe headache and vomiting due to high ICP followed by withholding blood thinner and strat mannitol to reduce ICP.
Prioritizing the 70-year-old with a fixed, dilated pupil in this situation is crucial because it may indicate a brain herniation, a potentially fatal situation that requires prompt medical attention. The 53-year-old who was taking blood thinners and had a really bad headache—likely an intracranial bleed—would come next. Following this, the 46-year-old with bladder incontinence may have cauda equina. Finally, the 19-year-old whose CT scan was normal but who had neck pain. Excellent example of crucial decision-making! 