Med 536 Communicating About Prognosis Workshop. Case 2
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1 Med 536 Communicating About Prognosis Workshop Case 2 ID / CC: 33 year-old man with intracranial hemorrhage History of the Presenting Illness 33 year-old man with a prior history of melanoma of the neck (status-post resection) was driving on the highway with his family when he developed a severe headache. He pulled over to the side of the road and then developed loss of consciousness. 911 was called and he was taken to an outside hospital where a Head CT revealed a large hemorrhage in the left parieto-occipital area and acute hydrocephalus. In the emergency room at that facility, his pupils reacted to light and he had intact cough, gag and corneal reflexes. He was then transferred to Harborview Medical Center for further management. Review of Systems Cannot be obtained Past Medical History Melanoma of the neck. Status-post excision Social History Married. 1 Child. Active duty military with 4 overseas deployments. Non-smoker. Occasional alcohol use. No illicit drug use Allergies None Medications Aspirin 81 mg daily Family History Unknown at time of admission Vitals Temperature 36.6 BP 120/67 HR 87 RR 10 (on mechanical ventilator) Ventilator Settings: AC TV 500 cc Set Rate 10. Actual Rate 10.FIO2 0.9 PEEP 5 Exam General: Head: Eyes: ENT: Lungs: Heart: Abdomen: Well-developed, well-nourished man. Intubated. Normocephalic, atraumatic. No icterus. ET Tube in situ. Moist oral mucosa. Clear to auscultation bilaterally. No crackles or wheezes Regular rate and rhythm. Normal S1, S2. No murmur, rubs, gallops. No distended neck veins. No lower extremity edema Soft, non-tender, non-distended. No organomegaly. + bowel tones
2 Skin: Neuro: Warm, no rashes. No petecchiae or purpura Pupils react to light bilateral (4 mm à 2 mm) Intact corneal reflexes. No cough, no gag. No response to voice or painful stimuli. Negative oculocephalic reflex. Unable to assess sensation. Normal muscle bulk and tone. Deep tendon reflexes not assessed Admission Laboratory Studies Chemistry Panel: Sodium: 145 Creatinine 1.0 Complete Blood Count: WBC 16 Hematocrit 40 Platelets 303 ABG: ph 7.25 PCO2 66 PO Blood alcohol level: 0 mg/dl (legal limit < 80 mg/dl) Toxicology Screen: Negative Admission Radiology Studies Chest Radiograph:
3 Chest CT: Head CT:
4 The Case Continues It is now 6 hours after the patient was admitted. The neurosurgeons opted not to take the patient to the operating room and ordered an MRI of the brain to determine the source of his bleeding. He remains hemodynamically stable and continues to have stable respiratory status on the ventilator. His neurologic exam is as follows: - Intubated, remains unconscious off sedative medications - Absent Corneal, papillary and oculocephalic reflexes. No cough, no gag - He is not over-breathing the ventilator - No response to verbal stimuli. - No motor response to pain - Toes down-going bilaterally; 2+, symmetric quadriceps or biceps tendon reflexes. Based on his clinical exam, formal brain death testing is performed. The results of this testing are as follows: Brain Death Examination Two separate neurologic examinations were performed 3 hours apart by different physicians. The results are as follows: Test Examiner #1 Examiner #2 Pupillary Response Absent Absent Corneal Reflex Absent Absent Oculovestibular Reflex Absent Absent Oculocephalic Reflex Absent Absent Cough Absent Absent Gag Absent Absent Motor Response to Pain Absent Absent Apnea Trial An arterial blood gas was performed documenting a P a CO 2 of 38 mm Hg. The patient was placed on an F I O 2 of 1.0 for 10 minutes and then disconnected from the ventilator. An anesthesia bag with was hooked up to the end of the endotracheal tube to monitor for evidence of respirations. Supplemental oxygen was delivered in a blow-by fashion through the anesthesia bag. The patient remained off the ventilator for a period of 10 minutes during which time no spontaneous respirations were detected. A blood gas performed at the end of the 10 minute period revealed that the P a CO 2 had risen to 63 mm Hg during the trial.
5 Questions To Consider What do the results of this test indicate? According to the law in the State of Washington, what is the implication of these test results? How would you explain the results of these tests to the patient s wife. What questions do you anticipate that she will ask and what would you say in response to those questions? Your Group s Tasks Task 1: One member of your group will stand up in front of the room and present a concise synopsis of the patient s clinical situation. Your goal is to summarize what initially happened, his clinical course and the results of the subsequent testing in 2 minutes. Task 2: One member of your group will have a conversation with the patient s wife, who has been joined by her parents and the patient s brother. They are awaiting the results of your examinations. Your task is to inform the mother of the results and explain the implications of these results. In other words, explain the clinical picture you are dealing with. You should then explain what will transpire from this point forward.
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