Patient is middle aged (early 60s), smokes a pack per day, calls EMS after falling off the toilet and being unable to get up secondary to left sided onset of weakness. Gets TPA after arriving in the E.R. after being found to have 90-100% occlusion to vessels I cannot now remember. Recovers some movement and function of left extremities, has significant left facial droop. Trauma during Foley attempt in ER leads to necessity of suprapubic cath. Admitted to Neuro ICU where patient goes into ETOH withdrawal, is vented and placed on Ativan GTT. Recovers from withdrawal after a few days, weaned from vent. Significant aphasia present, aspirating own secretions. Made strict NPO, NG tube placed for tube feeding and meds. Occasional need for oral suction.
Patient transferred to PCU. Left side nearly flaccid with minimal movement noted. Patient moans constantly, incomprehensible sounds, no sensible verbalizations. Follows commands unreliably. Not always responsive to voice. CXR shows aspiration pneumonia and patient is on Vanc and Merrem. On 4L NC, spo2 93%, SR in the 80s, SBP 130s. Elevated sodium with orders for 250 ml FW flushes q6h, returns even more elevated the following morning and FW flushes ordered q4h now. Patient moaning constantly, becomes diaphoretic. Gradually pulse increases to ST in the 110-120 range, patient becomes agitated, attempting to sit up. Follows no commands. Spo2 tanks to 89% on 4L NC after
breathing treatment, BP increases to 164/101. Obvious labored with see-saw respirations and mild supraclavicular contractions. Nonrebreather placed and patient placed sitting up to 90 degrees, spo2 improves to 99%. MD notified and ABGs are ordered, demonstrating respiratory alkalosis and metabolic alkalosis. CTA negative for PE. CT head shows no changes from previous. CXR shows no changes from previous. Cardiac enzymes, blood and urine cultures, EKG all pending at the time of transfer to ICU.
Ideas on what may have been going on with this patient and other courses of action that might have been taken? This isn't homework, it was my patient yesterday. I felt glad to recognize a problem and avoid a rapid response situation but patient's overall condition baffled me. Patient had been eating, following commands and making some verbalizations prior to transfer to stepdown. Decline was gradual over a few days and then culminated in rapid decline on my shift.
ETA- TMax 103.0 axillary
Feb 28, '14
by Esme12, ASN, BSN, RN
Any other co morbidity? Liver OK? Renal OK? diabetic?
Last edit by Esme12 on Feb 28, '14
Not diabetic. I did not see the CXR itself but read the report. It stated it was unchanged. AST/ALT elevated but not alarmingly so given alcoholic status.
In terms of eating, anecdotally from the spouse patient had been able to swallow some food while still in ICU. Obviously at some point someone realized the patient was aspirating due to NPO status and NGT present when the patient was transferred to PCU.
Patient did have a PICC line. Blood cultures were neg at the 24 hour mark.
Two things really threw me - high sodium despite free water flushes done religiously and metabolic and respiratory alkalosis. I would have expected respiratory acidosis.
Love all the questions you guys are asking. Helps my thought process. The day before the event the patient had been on D5W at 50 ml/hr. A new hospitalist came on rotation and stated strokes should never be on D5 and stopped it. I had never heard that before. Could the D5 have played a role? And if so, what?
Last edit by not.done.yet on Mar 1, '14