Alright guys...I have a lot of ICU experience, but little neuro. We dont keep head injuries since we havent found a neurosurgeon since the last one retired...blah blah blah....
Anyway, I have this pt that is post-op day four. She had an AAA and during surgery it was discovered that she has heparin antibodies. Obviously she threw micro-emboli all over the place. Her legs and feet are pretty much gone...feet have no cap refill but doppled pulses, so it seems that she clotted off her small vessels. So we know that the feet are gone.
She is now extubated and awake. She can tell you her name, and although she is hard of hearing, she can tell you where she is and answer simple questions. At times she does inappropriate things...stuttering...odd movements with her tongue. The big thing is that she strips...constantly. She doesnt pull her lines now...although she accidentally pulled back on her swan when she was still in post-op haze on the vent. She only takes her gown and sheet off.
When you ask her what she is doing she says "nothing." She doesnt know she is stripping and wont fight you when you put her clothes back on. I have had pts that pick at things before and they generally stop when you tell them too - anxiety, nervousness, etc. This I think is a head problem...I mean if clots go down, there is no way that one or two didnt go up, right?
So, all you neuro gurus...help out a MI/SI vet. What is the deal? and why is my surgeon so set against a head ct? "She is too unstable right now."
PS...off pressors. TPN/Lipids, base fluids, PRBCs, and Tigecilin only.
Dec 3, '05
Too unstable? We send ours down for emergency stat head CTs all the time. If it's for altered LOC a nurse must go with pt. Perhaps they don't want her lying flat? That's the only thing I can gather. As for the undressing, do you know what this woman's baseline was? I see it on my floor all the time. Unfortunately, there's not a lot we can do about it though.
Dec 3, '05
Sounds like she does have something neuro going on but what was she like "before"? What is her age? If she has a AAA you can bet she is a vasculopath so does she have underlying cerebral vessel disease? Or, and this is always worth thinking of, is she an undiagnosed Alzheimers/dementia. ANY surgery/stress will accelerate alzhiemers.
Jan 11, '06
Don't cardiac pt.s experience heightened sexual inhibition??
Jan 12, '06
Many of my pts like to get naked as well. Your pt does not sound too unstable for a CT.She is in definite need of a neuro consult.
Jan 12, '06
Sounds like a lacunar infarct may have happened (occurs commonly with occlusion of particular watershed areas).
Jan 18, '06
Since you tell me that your patient has developed HITT (heparin induced thrombcytopenia and thrombus) then I would assume that she has thrown a clot to someplace in her head. As a point of education, patients who have HITT react to heparin by forming clots. The confusion that she is exhibiting fits the scenario of a ischemic CVA. Any other questions....drop me a line.
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