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Introduction

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A 55-year-old right-handed woman presents to the emergency department (ED) because of sudden loss of consciousness. The patient has a history of tobacco smoking as well as poorly controlled hypertension for which she takes metoprolol and captopril. She is brought into the ED by emergency medical services (EMS), who transported her from a grocery store near her home. She is accompanied by her husband, who describes the sudden onset of headache quickly followed by paralysis of the right face, arm, and leg while they were shopping for food. EMS personnel report that during transport she stopped moving her left side, lost consciousness, developed dilated and unresponsive pupils, and had to undergo orotracheal intubation for airway protection. She received a neuromuscular blocking agent as well as propofol during the procedure. Intubation occurred 12 minutes prior to arrival in the ED.

She is evaluated immediately upon arrival and found to have a blood pressure (BP) of 212/123 mm Hg, respiratory rate (RR) of 12 breaths/min, heart rate (HR) of 121 beats per minute (bpm), temperature of 37.3°C (99.1°F), and O2 saturation of 98%. She is promptly placed on telemetry, two large-bore intravenous (IV) lines are placed, and a set of laboratory values is drawn. On physical examination, she is found to be unresponsive to painful stimuli. The orotracheal tube is at 23 cm to the lip and secured. Thoracic auscultation reveals clear breath sounds in both lung fields, S1, S2, and a loud S4. The point of maximal impulse (PMI) is displaced and pulses are palpable without difficulty. Funduscopy reveals retinal changes consistent with malignant hypertensive retinopathy. The abdomen is soft and nontender and there are no skin findings or stigmata. Neurologic examination performed off sedation shows no motor response to nasal tickle or deep sternal rub. The pupils are 7 mm and nonreactive to light. Corneal reflexes are absent on both sides. There are no spontaneous breaths and no gag response on manipulation of the endotracheal tube. Oculocephalic reflexes are absent and no "doll's- eye" responses are noted. Deep tendon reflexes are absent and no plantar response was elicited. The charge nurse in the ED has secured the patient's possessions including her wallet and driver's license.

As you prepare to transport the patient for a computed tomography (CT) scan, you ask her husband about the presence of advanced directives and find out that there is no written living will or oral advanced directives. Her husband asks you to "please save her no matter what." You inform him that she will be transported to the neurologic intensive care unit (ICU) immediately after the CT scan. The nonenhanced head CT scan is shown in Figure 53-1.

Laboratory results become available shortly afterward and reveal a normal comprehensive metabolic panel, complete blood count, toxicology screen, arterial blood gases (ABGs), cardiac ischemia markers, and coagulation tests.

When you return from radiology, the medical student assigned to the case asks ...

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