Sudden code & death of suspected meningitis pt... opinions please!

Published

Specializes in Critical Care- Medical ICU.

So I am trying to wrap my head around the death of my patient and I thought maybe some of your opinions/ advice/ previous experiences could possibly help.

Pt was a female in her 40s, newly diagnosed in Nov. with HIV after being hospitalized for PCP pneumonia. She came into the hospital this weekend c/o headache, neck stiffness and general malaise. Was brought via EMS after syncopal episode while at the store. Mild SOB also noted. Pt placed on 4 li NC maintaining sats well, was sinus tach, BP normal, RR around 30 T max 99.5. A little lethargic but appropriate. Bloodwork sent and CT & MRI brain done which showed some diffuse cerebral edema. They were suspecting cryptococcal meningitis and atypical pneumonia and sent blood for cryptococcal antigen (later came back positive.)

So she ends up admitted to the tele floor but after a couple hours becomes increasingly short of breath and saturating about 84%. ABG normal except for low O2. She was placed on NRB and sent to me around 4 am. She did well on arrival and rested comfortably for a couple hours.

During the day she became increasingly tachypneic, was tried on BiPAP with no effect. Around 4 pm we electively intubated her to decrease her work of breathing. She was easily intubated after being given etomidate, versed and morphine I believe.

Approximately 20 min after intubation, she became bradycardic (40's). MD requested a 12 lead but in the 10 seconds it took to walk down the hall and get the machine she went into pulseless V tach. She was coded for 20 minutes- progressed from Vtach-> Vfib-> PEA-> Asystole.

Any ideas as to what happened? One person mentioned herniation as a possibility. Someone mentioned that a couple minutes into the code her pupils were fixed and unequal.

She ended up being a medical examiner case. When I called the ME, she decided to take the case because of the fact an LP was never done for the suspected meningitis.

Sorry I just wrote a small book :) Opinions/ comments much appreciated.

Up Vote Up Vote ×
Specializes in ICU, prior telemetry experience.

Sounds like a presentation of herniation to me. Cerebral edema can be no joke! While bradycardia could have been attributed to RSI, followed with v-tach I wouldn't bet on it.

Odd to have no LP ordered though. Curious to see other posts.

Up Vote Up Vote ×
Specializes in Cardio/Pulmonary.

i agree that no lp seems super weird...

but definitely sounds like herniation...

sad :(

Up Vote Up Vote ×

Why wouldn't they have done an lp in this scenario? Makes absolutely no sense to me. I'm gonna agree with the others on herniation.

Up Vote Up Vote ×
Specializes in Critical Care- Medical ICU.

I don't know why they didn't do an LP! I feel a little bad that I didn't question that when I received her from the floor. Shouldn't they have done one before even admitting her? I feel like they should have and then could have sent her to Neuro ICU or something. I am not very familiar with the immediate care of suspected meningitis, but do they typically do LP right away or do they wait until the next morning if the patient is stable and it is the middle of the night. Either way, they didn't do one for her the next morning either, but I'm just curious about whats typical.

Up Vote Up Vote ×
Specializes in Telemetry, Case Management.

I know that two of my kids went to ER on seperate occasions, and once meningitis was suspected, an LP was done within the hour.......

Up Vote Up Vote ×

My guess is that LP was not performed because increased ICP (as evidenced by the CT findings) in the setting of acute bacterial meningitis is a contraindication to performing LP.

Up Vote Up Vote ×
Specializes in ICU, Telemetry.

I had a patient who had a stroke in the brainstem, herniated, and her course was almost exactly like what you described -- respiratory depression, biPap --> NRB --> vent. We didn't code mine, family went for the DNR, but I remember she brady'd down and died, just "Boom!" Went from being admitted with a TIA with no residual weakness at 8pm, talking, eating, watching TV and asking about what I'd heard about a local trial, okay at 9, okay at 10, found unresponsive at her 11pm neuro check and she was dead at 2am.

Maybe at a big flagship hospital with a neuro ICU you can do something for a herniating brainstem, but not in a rural hospital. It's a death sentence.

Up Vote Up Vote ×
My guess is that LP was not performed because increased ICP (as evidenced by the CT findings) in the setting of acute bacterial meningitis is a contraindication to performing LP.

Also, increading ICP per Cushings Triad would result in Bradycardia yes? Right until the patient coded she was tachy yes? That would seem a little odd. Was the ICP ever measured/calculated? Just a students curiosity here.

These types of real life situations are invaluable to us students.....thanks!!! Also, I would have expected to see high blood pressure/widening pulse pressure??

Up Vote Up Vote ×
Specializes in Critical Care- Medical ICU.

The patient had no evidence of cushings triad- she was sinus tachy, BP at her baseline of basically 120/80 and no respiratory depression, just tachypnea and labored breathing attributed to the pneumonia. She went straight from sinus tach to brady followed almost immediately by vtach. She maintained her mental status until she was knocked out for intubation. And no, an ICP was never measured.

It was a sad day. We deal with death on our unit on a daily basis but its just different when its sudden, not immediately expected and someone so young. The family,especially her children, were absolutely devastated.

Up Vote Up Vote ×

Wow, well I am sorry you are having to go through this. I reckon all involved are gonna have to wait it out for the ME report......

I dont understand how someone so stable can go south so quickly. How long was it from admit to code?

Up Vote Up Vote ×

Soooo help me out here guys, no elevated ICP = no herniation?

Up Vote Up Vote ×
+ Join the Discussion