Med 536 Communicating About Prognosis Workshop. Case 1

Transcription

1 Med 536 Communicating About Prognosis Workshop Case 1 ID / CC: 39 year-old woman status-post motor-vehicle collision History of the Presenting Illness Previously healthy 39 year-old woman was found in her car against a telephone pole. The medics were called and, upon arriving on the scene, found the patient unresponsive and without a pulse. She was intubated and CPR was performed with return of spontaneous circulation and then brought into the emergency room at Harborview Medical Center. It is unclear the duration of time she was without a pulse. From the time 911 was called to arrival of the medics was less than 5 minutes. Return of spontaneous circulation occurred 10 minutes after arrival on the scene. Review of Systems Cannot be obtained Past Medical History No known medical problems Social History Recently divorced; Has 3 children. Unknown occupation. Mother lives in the area Allergies No Known Drug Allergies Medications None Family History Unknown at time of admission Vitals Temperature 37.1 BP 120/67 HR 96 RR 31 (on mechanical ventilator) Exam General: Head: Eyes: ENT: Neck: Lungs: Intubated. In C-collar. Patient is having repeated jerking motions of her head and arms in a stereotyped manner that do not respond to benzodiazepines (myoclonic status epilepticus) Normocephalic, atraumatic. No lacerations. Pupils equally round and reactive to light. No icterus. No Subconjunctival hemorrhage. (+) Periorbital ecchymoses ET Tube in situ. Moist oral mucosa. No bloody drainage from nares; No hemotympanum C-collar Clear to auscultation bilaterally. No crackles or wheezes

2 Heart: Abdomen: Skin: Neuro: Tachycardic. Normal S1, S2. No murmur, rubs, gallops. Neck veins not visualized due to C-collar. No lower extremity edema Soft, non-tender, non-distended. No organomegaly. No seat-belt sign Warm, no rashes. Scattered abrasions on face and extremities with areas of ecchymoses Corneal, papillary and oculocephalic reflexes in tact. (+) cough. Patient over-breathes the ventilator s set rate. Repetitive jerking motions (myoclonic motions) as noted above. Unable to assess sensation. Normal muscle bulk and tone in all extremities. No response to verbal stimuli. No motor response to pain. Toes down-going bilaterally. Biceps and quadriceps tendon reflexes 2+ and symmetric. Admission Laboratory Studies Chemistry Panel: Sodium: 136 Bicarbonate 21 Creatinine 0.6 Complete Blood Count: WBC 23 Hematocrit 32 Platelets 205 ABG: ph 7.35 PCO2 36 PO2 162 HCO3 19 Blood alcohol level: 205 mg/dl (legal limit < 80 mg/dl) Toxicology Screen: + for marijuana Admission Radiology Studies Chest Radiograph: Head CT: no evidence of intracranial bleeding. No skull fractures. No midline shift. Normal size ventricles.

3 CT Cervical spine: Fracture of the C2 vertebrae with no evidence of underlying spinal cord injury The Case Continues Forty-eight hours after her arrest, the myoclonic jerking motions have subsided since she was started on medications after an electroencephalogram (EEG) revealed no evidence of seizure activity. She is hemodynamically stable and has adequate oxygenation after being put on antibiotics for a presumed aspiration pneumonia. Her renal function remains intact and she continues to make good urine output. Her neurologic exam is as follows: - Intubated, remains unconscious off sedative medications - Corneal, papillary and oculocephalic reflexes in tact. (+) cough. - She breathes at the ventilator s set rate but triggers her own breaths when put on CPAP. - No response to verbal stimuli; No motor response to pain - Toes down-going bilaterally; 2+, symmetric quadriceps or biceps tendon reflexes. Additional testing is performed to help assess her prognosis for awakening and regaining meaningful neurologic function. The results of the tests are as follows: Brain MRI Results (Performed within 24 hours of Admission) FINDINGS: Brain parenchyma is normal in signal intensity on all imagingsequence. No infarct, mass or hemorrhage is present. Ventricles are symmetrical and normal in size. There is no shift of midline. Vascular structures are normal in appearance. Small subcortical nonspecific foci are visualized within the cerebral hemispheres bilaterally. These findings are nonspecific there is no evidence of restricted diffusion to suggest acute infarct. No evidence of ischemic injury Summary: Nonspecific subcortical white matter foci, which might be not related to the trauma. No evidence of hemorrhage. No evidence of acute infarct.

4 Somatosensory Evoked Potentials ELECTRODIAGNOSTIC MEDICINE CONSULTATION HARBORVIEW MEDICAL CENTER Patient ID: Test Date: 12/29/2009 Name: Test Time: 6:23:15 PM DOB: 1/13/1970 Age: 39 year Referring Phys: Dr. Luks Gender: Female Physician: Dr. Robinson Report Date: 12/25/2009 Patient Complaints: This is a 39 year-old woman who had anoxic brain injury at least 20 min. due to an unwitnessed accident 12/23/09. She has remained unresponsive and is referred for SEPs to evaluate a prognosis for awakening. At time of testing she is given 50mg rocuronium at time of testing. Stimulation: Left, right median nerve. Recording: Median nerve: Erb s referred contralaterally; C5 spine referred to Fz; Fz referred to mastoid; contralateral scalp (C3' and C4') referred to Fz. Median SEP subcortical responses 3.1 Hz Trial P14M N13 C Erb N10M-P14M P9C-N13 C Norm absent <16 <14.9 <11.5 >0.6 >1.2 Right absent Left L-R Median SEP comab 1.1Hz Trial N35 N Norm <22 <30 <22 <22 <30 <30 >0.7 >0.7 >0.7 Right Left L-R Results: N35 - P45

5 Median n.: Cortical responses absent bilaterally. Subcortical responses present with normal latencies and amplitudes. Peripheral responses normal. Conclusions: Markedly Abnormal study - anoxic etiology. Absence of cortical responses to median nerve stimulation on both sides. In particular, responses absent bilaterally. Laboratory Work Neuron-specific Enolase (serum value): 45 mc/l Questions To Consider Based on the results of test you have been provided, what would you predict is the likelihood that she will regain consciousness? What options can you present to the patient s mother regarding her course of care from this point forward in light of her likelihood of waking up? What questions do you anticipate that the patient s mother 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, her clinical course and the results of the prognostic studies in 2 minutes. Task 2: One member of the group will have a conversation with the patient s mother who is awaiting the results of the somatosensory evoked potentials. With these results in hand, your task is to sit down with her and do three things: Offer a prognosis about her likelihood of waking up Present the options regarding her course of care Elicit an opinion from her as to which way she would like to go with her overall course of care.