Case Study: Solve A Neurologic Mystery

[Corey Narry]

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:

1. List possible explanations you would expect to hear from her medical team that could explain her neurologic presentation and why.
2. Tests you would anticipate.
3. Interventions you would provide as the bedside nurse and why.

Note: This is an actual case and the outcome is already established.

[PRNketamine]

Lamazeteacher, have you ever worked in an ICU?

[Corey Narry, MSN, RN, NP]

Tnmom3 said:

Serotonin syndrome from Paxil. It has hyperreflexia, agitation, high hr and temp. It can cause rhabdo. Tx w/ serotonin antagonist ?clonipine?

While the mainstay of treatment is supportive care, you are correct that there are other treatment recommendations for Serotonin Syndrome. Agitation is usually treated with Benzodiazepines. The patient in this case was on Propofol while intubated and this was working in terms of keeping her calm. It was also helping with her BP. HTN is also a feature of this syndrome and can be treated with IV infusion of Esmolol which she also didn't require. Some patients with a resulting autonomic instability end up with labile BP (highs and lows). The antidote is Cyproheptadine, a serotonin antagonist. We didn't start that without getting the blessing of Poison Control who actually felt that their suspicion is low.

[Corey Narry, MSN, RN, NP]

lamazeteacher,

Thanks for your input. I'm not speaking for everyone who responded but my feeling was that the comfort measures, repositioning, and ongoing assessment were implied and that nurses, especially those who work in the ICU, accept these as standard care for anyone who is intubated and unable to reposition themselves.

The patient did receive prn Fentanyl IV wich was the choice used because of its short acting effect that would still allow us to assess her neuro exam if we needed to. Standard interventions for VAP prophylaxis were done - oral care, head of bed elevation, etc. Turning and repositioning was done - our ICU has a turn team actually.

The point of my case study was not to prove that we are smarter than physicians. I am an advanced practice nurse and my role is actually more of a provider than a bedside nurse. However, I still feel that the bedside nurses I work with should be able to think of patient assessments, look at chest films, review labs, and tie them to possible physiologic processes. Our hospital promotes nurses' autonomy in these, short of actually being the provider.

The LP was done because the patient was on treatment for meningitis which we felt wasn't necessary but had to be proven that it didn't exist. MRI could have shown some changes associated with meningitis but not early during its course. In our opinion as the ICU team, the LP should have actually been done in the ED before she was started on meningeal doses of antibiotics.

[Corey Narry, MSN, RN, NP]

Also, discharge planners, social workers, dietitians, pharmacists, physical and occupational therapists exist and are part of the ICU team along with the intensivist, other providers (NP, fellow, resident), and nurse.

The patient wanted her independence and went home with 24-hour care which was arranged for her before she left. She was willing to pay for the service. PT and OT did asses her functional readiness to go home and felt that this was a reasonable discharge plan.

We are an ICU team, hence, we were not responsible for her primary care. She receives primary care from a local physician who we got in touch with and updated of her hospital course. She left the hospital with a follow up appointment with her primary care physician. Neurology was involved in her case as a consulted service. They also wanted to see her as an out-patient.

[tinyonern]

Very interesting case. My first reaction was bladder infection caused mild confusion, which led to mis-taking meds, which led to NMS or serotonin syndrome, which led to... I never worked with adults (hospitalized) other than in psych, and part of that was in gero psych. Towards the end of my working career I worked telephonic disease management with the elderly, and one of the things I tried to stress was having a safety plan in place. It didn't have to be elaborate, just a phone call daily from a neighbor, someone checking if they didn't pick up paper, pull up blinds, or something that they did daily that would be noticed if they didn't do it. This person might still have gotten sick, but maybe it wouldn't have been 3 days before it was noticed. In my experience, many seniors want to remain independent, not be a burden, and many aren't willing to have strangers in their homes, but are willing to develop simple safety plans with neighbors.

[weirdscience]

Juan, this was a GREAT post. Please share more like this if you have the chance!

[judihh]

I have not a clue---- I myself am 71 and am not particularly fond of this scenario. Is she still smoking? Why is she not doing her own light housework? What does she do socially? Does she still drive? Is her only social life her 20 pack deadly friends? After she does improve she should be plugged into a stop smoking group. And her activity should be questioned and improved if need. As it is she is an accident waiting to happen. At the very least she should have a "life alert", as the next time she may be found DEAD!

[jstrawberry]

Rabies?

[lamazeteacher]

It's good to know that there's now "turn teams" doing that very necessary aspect of patient care, in acute care settings, especially for COPD PATIENTS; and some discharge planning occurred when the patient was discharged. It seems that the plan was economically based ("the patient was willing to pay"). Was her family present to oversee coverage, however? Was the 24 hour care provided by an R.N. or uncertified aide? Did her family physician concur and order discharge meds, or was it assumed that her former regimen was adequate? What preventive plans to assure that rehospitalization or repeat performance would occur? One of the biggest costs for Medicare, is repeated hospitalization, largely based on assumptions that appropriate care and followup happen.

To answer the impertinent question regarding my direct ICU experience, I haven't staffed ICU in the past few decades, and I have done Home Health Nursing after my advanced age caused physical limitations, which inspired me to change my role at work. One of the most neglected needs of nurses, is a pension plan. We work at different facilities according to opportunities to advance, and the work we do is full of stress. However age creeps in with destructive capacity, even though we have delayed those changes, considerably.

When I was working in hospitals, I was an Infection Control Nurse and Nursing Educator, in the late '80s and early '90s. After that I worked to promote umbilical cord blood stem cell preservation. I believe that stem cell treatment will revolutionize medical and nursing care in the future. First, however it's necessary for innovative thinking and observation of disease process folks to get off their "high horses" and realize that "after the fact" care wastes time, lives, and money. It's quality of life that is essential as the objective for our profession. To that end, quality of nursing care is intrinsic!

[Esme12, ASN, BSN, RN]

I think that educating bedside nurses with case studies is important so that they can recognize the complications and symptoms of something so they can better care for their patients. While I have never worked at a facility the employed "turn Teams" and the bedside nurse was responsible for that care....it is understood that these basic needs are performed as the standard of care.......so what else does the patient need....right now.

We all know that at 3 am and the patient presents with some symptom or deterioration it is the nurse who call the MD and acts as their "eyes" and assess the patient for their needs and Ideas....how many times have I said wouldn't you like to order xyz? or wouldn't a xyz be helpful? so that when they ask WHY...you can have an intelligent answer for them with rationale.

Admittedly.....I have been a nurse for 35 years.....and I know very little about discharge planning for I have always left that up to the experts so that they could organize, brainstorm, and advocate for what the patients need at home.

Unfortunately, is is all about money.....medicare restricts what it will pay for and why they will/will not pay for any govern treatment/care/therapy and unfortunately many of the elderly and disable just don't have disposable income to pay cash and the their quality of outpatient/home care is affected.

[MauraRN]

barrymedic said:

Thinking about serotonin syndrome also. An over dose of her paxil may have caused it.

I was thinking along the same line. SSRI overdoses are bears. On the other side of the coin, stopping her paxil or lorazepam can cause problems too. Paxil potentiates many other meds, including OTC/herbals. Could lead to the LOC, which led to the PNA, etc.

[emesibaja]

Just looking at ems data, one could speculate pulmonary edema related to possibly cardiomyopathy and kidney failure. Also over dose with ativan and ems giving narc an at scene could explained her agitation later.

If she went into ARF weather is cardiac in origin or medicine or excessive fluid related that could explained her agitation due to build up of toxins or hypoxia causing ams.

Ct ruled out stroke, edema could be due to fall, if she had an arrhythmia there is no test to test for it, cxr showed opacity so one could say bc her copd she had CAP aggravated by her copd and it got to the point that made her hypoxic and made it collapsed. Which her temp and wbc support that idea.

Vs suggest pulm edema, cxr didn't show nothing bad so it has to be resp related supporting CAP, lactate wasn't to bad, her skin is warm so based on that we can assume she is not in shocked yet bc if she was her skin would cold among other symptoms, so that for not rules out ami.

So most likely dx CAP that explains temp, wbc cxr findings and mental status.

I would imagine md would order echo, bnp, ekg and trops that would rule out cardiac culprit.

Cbc, bmp, repeat lactic, amylase, lipase, d dimers, blood gas and if a tlc is available a cvp and a mixed venous, that will provide a baseline metabolic picture it will also assessment major organs, cvp will assess fluid status and drive certain therapy , mixed venous will assess cardiac and tissue status .

Blood cultute, u a cult and sputum cult

Depending on cardiac work up results a cardiac cath might be needed .

Since Ct was negative no masses were shown of pt did seized based on ct finding not rt nothing acute so they may order a neuro consult plus eeg.

Also carotid us to assess blood to brain and possible tia.

The results will drive medical and some or nursing care but normal icu care is require neuro checks, urine output, rhythm strip, vs, lung sounds, pulses, gi sounds and size since a decline in that will indicate worsening condition.

Good case, it makes you think