RT Book, Section
A1 Sharma, Raman
A1 Dangayach, Neha
A1 K. Gidwani, Umesh
A2 Lee, Kiwon
SR Print(0)
ID 1143956988
T1 Management of Cardiopulmonary Devices at the End of Life
T2 The NeuroICU Book, 2e
YR 2017
FD 2017
PB McGraw-Hill Education
PP New York, NY
SN 9780071841443
LK neurology.mhmedical.com/content.aspx?aid=1143956988
RD 2024/04/24
AB A  65-year-old  man  is  admitted  to  the  neurologic  intensive  care  unit  (NeuroICU)  for  altered  mental  status.  He  was  found  “down”  by  his  family  at  10:00  am  on  the  morning  of  admission  and  was  last  known  to  be  normal  at  11:00  pm  the  night  before.  In  the  field,  emergency  medical  services  (EMS)  documented  his  Glasgow  Coma  Scale  score  as  E2V3M3,  blood  pressure  (BP),  220/110  mm  Hg;  heart  rate,  60  with  an  A-V  paced  rhythm;  respiration  rate  (RR),  10,  saturating  98%  on  100%  a  nonrebreather  mask;  bilateral  sluggishly  reactive  pupils,  4→2;  doll’s  eye  test,  minimal  bilaterally;  and  extensor  posturing  bilateral  upper  and  lower  extremities  to  deep  painful  stimuli.  No  external  signs  of  trauma.  Patient  was  intubated  in  the  field,  and  a  tertiary  stroke  center  in  the  vicinity  was  notified  with  activation  of  a  stroke  code.  On  arrival  to  the  emergency  department  (ED),  patient  was  received  by  the  ED  and  stroke  teams.The  past  medical  history  was  significant  for  CAD  s/p  CABG  in  2010,  DM-II,  systolic  HF  due  to  ischemic  cardiomyopathy  (EF  25%)  s/p  drug  eluting  stent  to  LAD  3  months  ago,  AVR  complicated  by  complete  heart  block  s/p  BiV  ICD/PPM  in  2011.  His  medications  include  ASA  81  mg,  Plavix  75  mg,  atorvastatin  40  mg,  lisinopril  40  mg,  metoprolol  XL  50  mg  q12h,  Lantus  40  units  SQ  qhs.On  arrival  his  BP  is  160/90  mm  Hg,  and  he  is  sedated  on  a  propofol  drip.  His  examination  is  similar  to  EMS  initial  exam.  The  stroke  team  is  concerned  for  a  top  of  the  basilar  clot  vs  a  massive  intracranial  hemorrhage  (ICH).  He  is  taken  for  a  stat  head  CT,  which  shows  a  32  cc  left  putaminal  hemorrhage  with  intraventricular  hemorrhage  (IVH)  in  bilateral  lateral  ventricles  and  casting  of  fourth  ventricle  with  acute  obstructive  hydrocephalus.  He  is  given  a  mannitol  bolus  of  100  g  stat,  hyperventilated;  the  head  of  bed  is  maintained  at  30°.  The  ED  team  calls  for  a  stat  neurosurgery  consult  for  extraventricular  drain  (EVD)  placement  and  possible  clot  evacuation.  SBP  is  maintained  between  100  and  140  mm  Hg  with  a  nicardipine  drip,  and  2  doses  of  23.4%  saline  are  given.  The  family  is  updated  about  the  massive  ICH  and  hydrocephalus.  They  are  informed  about  the  potential  risk  of  in-stent  thrombosis  with  anti-platelet  reversal,  and  the  patient  is  given  one  pack  SDU  platelets  and  DDAVP,  0.3  μg/kg  ×1.  The  neurosurgery  team  places  an  EVD  using  a  right  frontal  approach.  The  initial  ICP  is  30  mm  Hg.  Clot  evacuation  is  not  pursued  given  the  deep  location  of  the  hematoma,  and  the  patient  is  transferred  to  the  NeuroICU.With  risk  of  in-stent  thrombosis,  the  plan  is  to  restart  aspirin  about  day  7  but  hold  off  on  Plavix  while  the  EVD  is  in  place.  Post-bleed  day  4,  the  patient  develops  a  Tmax  of  39.8,  and  he  is  pan-cultured  and  started  on  broad  spectrum  antibiotics-vancomycin  and  cefepime;  CSF  is  sent  from  the  EVD.  His  examination  worsened:  GCS,  E1VtM1.  Cerebrospinal  fluid  Gram  stain  shows  few  GPCs  in  clusters,  indicating  the  development  of  ventriculitis.The  patient’s  ICH  score  is  3  and  his  30-day  mortality  is  ...