This is a case study involving an elderly female with complex medical history who presented with altered mental status of unclear etiology. The patient in this case is unable to give a history.
There are no reliable sources who witnessed the events leading to patient presentation making it more difficult to ascertain the etiology of her condition. The author hopes to elicit a discussion of her case among peers in critical care nursing.
Background / Social History
RS is a 70-year-old female who lives independently in a first-floor apartment in the city. She has no close relatives but has neighbors who know her very well and check in on her from time to time. She hires a cleaning lady that does her house cleaning and laundry every week. Her nearest relative is a niece who lives in the same state but is 8 hours away by car.
Past History
Her medical history includes anxiety disorder, hypertension, hyperlipidemia, COPD, and mild kidney insufficiency.
She has a 40 pack/year history of smoking.
She has no known allergies.
Medications
Paroxetine 20 mg daily
Lorazepam 1 mg daily as needed for anxiety
Losartan 100 mg daily
Amlodipine 10 mg daily
Simvastatin 40 mg daily
Tiotropium 18 mcg inhaled daily
Albuterol MDI 2 puffs 4 times a day as needed
Present History / CC
On the day of her ED admission, her niece had been calling her phone and had been unable to get hold of her. Her niece called a neighbor who stated that she has not seen RS in 3 days. Concerned about RS's condition, the neighbor knocked on her door and heard no response. Luckily she was able to open the door as it was unlocked. Upon entering the living room, the neighbor found RS lying unconscious on the floor. She had frothy secretions from her mouth and had urinated on herself. She immediately called 911. She was intubated at the scene by EMS responders for airway protection due to her altered mental status.
Vital Signs
BP 180/100
HR 110
RR 32
T 38.5 C
O2sat 88% on RA prior to intubation
Diagnostic Studies
In the ED, RS pertinent labs showed a WBC of 15,000 mm3, a lactate of 2.5 mmol/L, and CPK of 20,000 U/L. Neurologic exam was significant for agitation and inability to follow commands with sedation wean. She was hyperreflexic with increased muscle tone. She is moving all her extremities equally and has no abnormal pupillary response. She is sedated on Propofol. CV exam reveals sinus tachycardia with BP of 110/50, her skin is warm to touch. Respiratory exam reveals rhonchi in upper lung fields with moderate white secretions via ET tube
ABG: 7.36, 38, 82, 19, -3, 100% on ACVC: 16X400, FiO2 of 0.5 PEEP of 5.
CXR reveals mild cardiomegaly, a hyperinflated lung silhouette and mild RLL opacity.
Non-contrast CT Scan of her brain showed focal vasogenic edema in the basal ganglia.
The remainder of the exam revealed normal findings.
The ED was particularly busy that evening so RS was immediately transferred out to ICU without further testing in the ED. Because of her complex medical condition, she was transferred to the MICU under your care as her primary RN.
What thoughts run in your head that could possibly explain what caused RS's presentation?
What further testing would you anticipate?
How would you care for RS as her nurse?
For this exercise to be fun and informative, answer in the following manner:
List possible explanations you would expect to hear from her medical team that could explain her neurologic presentation and why.
Tests you would anticipate.
Interventions you would provide as the bedside nurse and why.
Note: This is an actual case and the outcome is already established.
1) first thing that comes to my mind is the patient is post-ictal. The frothy sputum indicates either pulmonary edema but is also very common with seizures. She could and most likely has an aspiration pneumonia secondary to seizure activity. She has skeletal muscle breakdown secondary to being on the ground for undetermined amount of time. With her CPK of 20000 she probably was on the floor quite some time and will most likely have rhabdomyolosis.
2) serial CPK levels every 12 hours, aggressive crystalloid hydration, renal consultation, loading dose of Phenytoin or utilize Keppra, control hypertension, keep patient sedated and allow for brain edema to decrease. Prevent hypertension, prevent acidosis, keep K on upper side of normal, monitor kidney function closely, antibiotics for aspiration pneumonia and begin feeding the patient via tube feeds as soon as possible.
Specializes in Vents, Telemetry, Home Care, Home infusion.
Don't know how I missed this thread when first posted in 2013. Great responses from members listing body system assessment, suggested labs/diagnostic testing and clinical nursing considerations. Learned a new diagnosis today.
Rhabdomyolysis after lying on the floor a long time. The very high CPK and moderate lactate fit this. Muscle breakdown can push potassium up and strain her kidneys.
Aspiration pneumonia leading to early sepsis. She was found on the floor, now has fever, high white count, right lower-lobe shadow, rhonchi, and white secretions in the tube.
Serotonin toxicity from too much paroxetine or a mix with an unknown substance. She is agitated, stiff, and hyper-reflexic which are classic clues.
New stroke or small brain bleed. The CT shows basal ganglia edema and her blood pressure was high when found.
A mix of all the above. Elderly patients often have several problems at once.
2. Tests I would expect
Recheck CPK, serum myoglobin, basic metabolic panel, and creatinine every four hours to track muscle injury and kidney function.
Blood, urine, and sputum cultures plus a procalcitonin before starting antibiotics to target the infection source.
MRI or CT angiography of the brain to clarify the basal ganglia change.
Toxicology screen and paroxetine level to confirm or rule out serotonin syndrome.
Continuous EEG if her agitation or rigidity raises concern for non-convulsive seizures.
Repeat chest X-ray or chest CT after twelve to twenty-four hours to watch the infiltrate.
3. Immediate bedside care
-Keep the head of bed at thirty degrees and give oral care every four hours to lower ventilator pneumonia risk.
-Maintain two large-bore IV lines and run isotonic fluids unless lung status worsens. Aim for at least sixty milliliters per hour urine. Send urine for myoglobin.
-Draw labs and cultures quickly, then start broad-spectrum antibiotics as ordered.
-Place her on continuous cardiac monitoring. Check potassium, ionized calcium, magnesium, and phosphate every four hours. Treat promptly if potassium rises.
-Give scheduled acetaminophen and use a cooling blanket if temperature stays above thirty-eight point five to reduce metabolic load.
-Pause sedation each shift for a focused neuro exam. If she shows new clonus or tremors, alert the team about serotonin syndrome and ask about cyproheptadine.
-Turn every two hours, apply heel protectors, and begin passive range of motion to protect skin and joints.
-Update her niece by phone, involve social work, and start planning for rehab since she lives alone.
-Keep seizure pads at the bedside and suction ready because she is at higher risk for aspiration and seizures.
ives
1 Post
1) first thing that comes to my mind is the patient is post-ictal. The frothy sputum indicates either pulmonary edema but is also very common with seizures. She could and most likely has an aspiration pneumonia secondary to seizure activity. She has skeletal muscle breakdown secondary to being on the ground for undetermined amount of time. With her CPK of 20000 she probably was on the floor quite some time and will most likely have rhabdomyolosis.
2) serial CPK levels every 12 hours, aggressive crystalloid hydration, renal consultation, loading dose of Phenytoin or utilize Keppra, control hypertension, keep patient sedated and allow for brain edema to decrease. Prevent hypertension, prevent acidosis, keep K on upper side of normal, monitor kidney function closely, antibiotics for aspiration pneumonia and begin feeding the patient via tube feeds as soon as possible.