Effective nursing triage and stroke code activation in acute hypertensive intracerebral haemorrhage presenting with sudden loss of consciousness

Effective nursing triage and stroke code activation in acute hypertensive intracerebral haemorrhage presenting with sudden loss of consciousness: An emergency department case report

Muthulakshmi M^1*, Dr. Meena², Deepa Rani Alagarsamy³, Lydia Annie J⁴

¹Emergency Department Nursing Incharge, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu

²HOD, Emergency medicine, Kauvery hospital, Radial Road, Chennai, Tamil Nadu

³Deputy Nursing superintendent, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu

⁴General Manager Clinical Operation, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu

*Correspondence

Abstract

Intracerebral haemorrhage (ICH) is a life-threatening neurological emergency commonly associated with uncontrolled hypertension. Early recognition and prompt management are essential to reduce mortality and neurological complications. This case report describes a 76-year-old female who presented to the emergency department with sudden onset of giddiness, severe headache, vomiting, and loss of consciousness. On arrival, the patient had a Glasgow Coma Scale (GCS) score of E₁V₁M₄, bilateral sluggish pupils, tachycardia, and severe hypertension with blood pressure measuring 260/140 mmHg. Immediate stroke code activation was initiated, and urgent non-contrast computed tomography (CT) of the brain revealed acute intracerebral Haemorrhage. Emergency management included oxygen therapy, intravenous access, and antihypertensive therapy, Anti- oedematous and continuous neurological monitoring. The patient was subsequently admitted to the intensive care unit (ICU) for further management. This case highlights the importance of rapid stroke recognition, early imaging, and coordinated emergency nursing care in improving patient outcomes in hypertensive intracerebral haemorrhage.

Key words: Intracerebral Haemorrhage; Hypertensive Crisis; Stroke Emergency; Emergency Nursing Care; Computed Tomography Brain; Neurological Monitoring

Introduction

Intracerebral haemorrhage is a serious subtype of stroke caused by bleeding within the brain parenchyma. It accounts for approximately 10–15% of all stroke cases and is associated with significantly higher mortality compared to ischemic stroke. Uncontrolled hypertension remains the most common cause of spontaneous intracerebral Haemorrhage, leading to rupture of small penetrating cerebral arteries. Patients often present with sudden neurological symptoms including headache, vomiting, altered consciousness, and focal neurological deficits. Early identification, rapid diagnostic imaging, and prompt medical management are essential to reduce complications and improve survival outcomes. Emergency nurses play a crucial role in early stroke recognition, neurological monitoring, and initiation of life-saving interventions.

Case Presentation

A 76-year-old female was brought to the emergency department by relatives following a sudden episode of giddiness and fall at home. The patient reportedly developed severe headache followed by repeated episodes of vomiting. Approximately one hour later, the patient became unresponsive. Due to progressive deterioration in neurological status, the patient was transported to the emergency department for urgent medical evaluation

Chief Complaints: Sudden onset giddiness and fall, Severe headache, Multiple episodes of vomiting, Sudden loss of consciousness

Clinical Findings

On arrival at the emergency department, the patient was unresponsive.

Clinical examination revealed:

Glasgow Coma Scale (GCS) E1 V1 M4

Pupil examination: Bilateral sluggish reaction (2 mm)
Oxygen saturation: 98% on 6 L/min oxygen via face mask.
Pulse rate: 112 beats per minute
Blood pressure: 260/140 mmHg

The patient underwent Due to low GCS elective endotracheal intubation for airway protection and ventilatory support. These findings suggested a hypertensive emergency with possible intracranial Haemorrhage.

Investigations and Results

Initial laboratory investigations were performed to evaluate the patient’s clinical status and rule out metabolic causes of altered consciousness.

Baseline investigations included:

Complete blood count
Blood glucose levels
Serum electrolytes
Renal function tests
Liver function test

Laboratory investigations were within normal limits. However, the patient presented with severe hypertension indicating hypertensive crisis.

Radiological Investigation

Urgent non-contrast CT brain imaging was performed following stroke code activation. CT brain findings demonstrated:

Acute intracerebral Haemorrhage
Hyperdense area indicating bleeding within brain parenchyma
Findings consistent with Haemorrhagic stroke.

CT imaging confirmed the diagnosis and guided further management.

Diagnosis

CT brain revealed acute intracerebral Haemorrhage involving the basal ganglia region with surrounding oedema diagnosed with acute Hypertensive Intracerebral Haemorrhage and Intraventricular Haemorrhage with Decreased Consciousness.

Emergency Nurse Effective Triage Management

Emergency nurses play a crucial role in the early identification and rapid management of stroke emergencies. Effective triage in the emergency department is essential to ensure timely diagnosis, rapid intervention, and improved patient outcomes in cases of acute intracerebral Haemorrhage.

In this case, the emergency nursing team demonstrated prompt recognition of critical neurological symptoms, including sudden loss of consciousness, severe headache, vomiting, and extremely elevated blood pressure. These clinical findings immediately raised suspicion of a neurological emergency requiring urgent evaluation.

Upon arrival at the emergency department, the patient was prioritized under the high-acuity triage category, enabling immediate clinical assessment. The emergency nurse rapidly performed an initial neurological evaluation using the Glasgow Coma Scale (GCS), assessed pupil reaction, monitored vital signs, and identified severe hypertension with blood pressure measuring 260/140 mmHg.

Recognizing the possibility of acute intracranial Haemorrhage, the emergency nurse promptly initiated the stroke code activation protocol. Early activation of the stroke protocol facilitated rapid multidisciplinary coordination involving emergency physicians, radiology staff, and critical care teams.

The emergency nursing interventions included:

Rapid triage assessment and prioritization
Continuous monitoring of vital parameters
Neurological assessment using Glasgow Coma Scale
Immediate oxygen administration
Establishment of intravenous access
Preparation for urgent CT brain imaging
Coordination with the stroke response team

Through efficient triage management and rapid stroke protocol activation, the emergency nurse significantly reduced diagnostic delays and ensured early initiation of lifesaving interventions.

Effective emergency nursing triage is therefore a key determinant in improving survival outcomes and reducing neurological complications in patients presenting with acute hypertensive intracerebral Haemorrhage.

Triage Timeline

09:00 AM – Sudden giddiness and fall with severe headache
09:15–09:45 AM – Multiple episodes of vomiting
10:00 AM – Patient became unresponsive
11:50 AM – Arrival at emergency department
Immediately on arrival – GCS E1V1M4, BP 260/140 mmHg
Stroke code activation – Emergency stroke protocol initiated
CT brain – Intracerebral Haemorrhage confirmed
Emergency management – Oxygen, IV access, antihypertensive
ICU transfer – Continuous monitoring initiated

Key Learning Points

Uncontrolled hypertension is a major risk factor for intracerebral Haemorrhage.
Sudden headache, vomiting, and loss of consciousness are important warning signs of intracranial bleeding.
Rapid stroke code activation reduces treatment delays.
CT brain remains the gold-standard imaging modality for diagnosing intracerebral Haemorrhage.
Emergency nurses play a critical role in early stroke recognition and patient monitoring.

Outcome

Following emergency stabilization, the patient was admitted to the ICU for continuous monitoring and management of intracerebral Haemorrhage and hypertensive crisis.

Discharge

After stabilization, the patient was discharged with instructions for:

Strict blood pressure monitoring
Adherence to antihypertensive medications
Regular neurological follow-up
Lifestyle modifications

Discussion

Hypertensive intracerebral Haemorrhage occurs due to chronic damage to small penetrating cerebral arteries caused by long-standing hypertension. This vascular damage can lead to vessel rupture and bleeding within brain tissue. Common sites include the basal ganglia, thalamus, pons, and cerebellum. Early diagnosis through CT brain imaging and rapid stroke code activation significantly improves patient outcomes.

Nursing Leadership Enabled

Emergency nurses contribute significantly by:

Early recognition of stroke symptoms
Rapid triage and stroke code activation
Continuous neurological monitoring
Administration of emergency medications
Coordination with multidisciplinary teams

Conclusion

Hypertensive intracerebral Haemorrhage is a critical neurological emergency requiring early recognition, rapid imaging, and immediate management. Emergency nurses play a vital role in improving outcomes through prompt assessment and coordinated care.

References

American Heart Association Stroke Guidelines-2026
World Health Organization Global Stroke Management Guidelines.
The Lancet Neurology Review of Intracerebral Haemorrhage Management.

Effective nursing triage and stroke code activation in acute hypertensive intracerebral haemorrhage presenting with sudden loss of consciousness

Effective nursing triage and stroke code activation in acute hypertensive intracerebral haemorrhage presenting with sudden loss of consciousness: An emergency department case report

Muthulakshmi M1*, Dr. Meena2, Deepa Rani Alagarsamy3, Lydia Annie J4

Nightingale Journals

Muthulakshmi M^1*, Dr. Meena², Deepa Rani Alagarsamy³, Lydia Annie J⁴