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

[IheartICUnursing]

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.

[Anna Flaxis, BSN, RN]

I wonder what the doc's reasoning was for NOT doing an LP.....

Again, because cerebral edema on CT is a contraindication to performing LP. Performing LP under these circumstances increases the risk of herniation, and *should NOT be done*. They did the *right* thing by omitting the LP in this case.

[CompleteUnknown]

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?

Mindlor, I'm curious why you think that - it's certainly not a rare thing. A poor outcome is not always the result of a nurse 'missing the signs of a downward trend' which is what a lot of people seem to believe. I can sort of understand it when the general public thinks that, but it's sad when nurses believe it too.

I know you're still a student, but there was a thread on here a while back where some of the posters were pretty much saying that if only floor nurses would assess their patients properly, rapid responses, codes, and transfers to ICU could be prevented.

[KelRN215, BSN, RN]

Mindlor, I'm curious why you think that - it's certainly not a rare thing. A poor outcome is not always the result of a nurse 'missing the signs of a downward trend' which is what a lot of people seem to believe. I can sort of understand it when the general public thinks that, but it's sad when nurses believe it too.

I know you're still a student, but there was a thread on here a while back where some of the posters were pretty much saying that if only floor nurses would assess their patients properly, rapid responses, codes, and transfers to ICU could be prevented.

Exactly! That's what herniation is, it's not a slow process. I have seen patients go from stable HR, BP, RR, O2 sat, etc. to HR of 40, O2 sat of 50 and finally asystole within seconds. Bacterial meningitis is one of those things that kills that quickly. Someone can present with a headache in the afternoon and be dead that evening.

[Horseshoe, BSN, RN]

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

If you think about it, I'm sure you realize that sudden death, while not a common event, is certainly not unheard of and no mystery. Have you ever heard of a young athlete suddenly dropping dead while on the basketball court, the soccer field, or at football practice? Stable one minute, dead the next. It happens.

I was talking to a patient once who seemed just fine several hours after a cardiac cath. He was relaxed and happy, talking about his upcoming vacation. Suddenly his eyes rolled back in his head, and he became unresponsive. Monitor showed v-fib. We coded him, sent him back to the cath lab, and he died there.

A friend of mine was working on a pediatric floor. Her adolescent patient, a teen boy with a chronic condition, interrupted her during a normal conversation and said, "Mary, I'm going down." And he died right there while looked at him with her mouth agape.

[Corey Narry, MSN, RN, NP]

Juan de la cruz, I really appreciate the comment about the effects of the induction and RSI. I was wondering, since the code happened shortly thereafter, if the intubation may have had any effect in pushing her over the edge.

Intubation in and of itself carries a risk of causing bradycardia. One cause is attributed to vagal reflex bradycardia that occurs in the setting of the transient hypoxia during intubation. It is a protective mechanism because it reduces oxygen consumption to allow available oxygen to flow into the vital organs. However, providers pre-oxygenate prior to intubation to minimize the mechanism causing this type of bradycardia during intubation. The second cause of bradycardia is attributed to laryngoscopy. Manipulation or stimulation of the laryngopharynx provokes vagal nerves that are present in this structure thus leading to bradycardia. Induction drugs can also cause bradycardia especially the opiods but Etomidate isn't usually associated with bradycardia. Certainly, healthy individuals could easily recover from these vagal responses but certainly not patients with ongoing cardiac issues and shock physiology as can be seen in sepsis. Some providers advocate the use of Atropine with all the other induction agents but this practice is not universally accepted. In our ICU, we always have emergency drugs on hand in addition to the induction agents specifically Neosynephrine, Ephedrine, and even Epinephrine syringes in anticipation of mishaps that could happen after intubation especially in terms of hemodynamic instability. It's not fair on my part to assume any wrongdoing done in your patient's case as I was not there. It actually sounds like this patient was really sick and things like this could easily happen even in the best of circumstances.

[diva rn, BSN, RN]

In addition, bacterial meningitis is very deadly and very swift. When I was still working PICU, we had a newly diagnosed 8 year old little girl who was being transported in to us from another hospital...the trip was 4 hours from door to door with lights and sirens (they couldn't fly her due to weather that day)...she was alert, oriented, talking, and totally normal when she left the other hospital...4 hours later...when they pulled into our emergency bay...they were coding her!!!!!!!

She never made it to our PICU...she was basically doa....they worked on her for hours but nothing....

That's how someone "stable" can not only go south...but can DIE in a matter of hours..

It was tragic for the parents who were pulled up in their car a little while later and had no clue..when they saw her she was sick...but talking and smiling...

and tragic for everyone.

[xtxrn, ASN, RN]

Again, because cerebral edema on CT is a contraindication to performing LP. Performing LP under these circumstances increases the risk of herniation, and *should NOT be done*. They did the *right* thing by omitting the LP in this case.

Gotcha !! Thanks- I misread when the LP was opted against :)