Sinai Hospital of Baltimore

1
Sinai Hospital of Baltimore

• General Surgery
• Morbidity Mortality Conference
• 7/26/06

2
Chief Complaint/HPI

• MK 63 y/o AA F with significant HX of DM, ESRD,
  HTN, and Seizure disorder admitted on 7/11 to SH
  after becoming confused and experienced multiple
  seizure episodes
• Total of three seizures witnessed by husband,
  each lasting approximately 6-7 minutes
• Family states patient was experiencing
  intermittent seizure episodes for the last two
  years
• Patient noncompliant with medications

3
PMHx

• DM
• ESRD on HD
• Seizure Disorder
• HTN
• Severe Cardiomyopathy (EF of 15)
• Major Depression
• Alzheimer Disease

4
PSHx

• Hysterectomy
• Hip Surgery

5
Medications

• Norvasc
• Coreg
• Klonopin
• Colace
• Lisinopril
• Flexeril
• Ultram

6
Allergies

• IV Contrast

7
Vitals Labs

• T-36.1 P-95-125 BP-215/113 RR-18
• Na- 142 K- 3.4 Cl- 98 CO2-23
• BUN/Crea- 40/8.1 Gluc-121
• WBC-9.8 Hgb/Hct- 13.7/42.4 Plts- 126
• ABG- AC 12/600/40/5
• 7.38/39.6/151/23.9/99
• EKG- Sinus Tachycardia 110 bpm
• EEG- intermittent rhythmic sharpwaves
  (non-convulsive status epilepticus)

8
Physical Exam

• HEENT- Opaque R Cornea, L Pupil reactive
• Neuro- unresponsive except to noxious stimuli
• CVS- S1S2 No Murmurs
• Lung- Mild bibasilar crackles LgtR no wheezing
• ABD- Soft NT ND BS-active
• EXT- No clubbing, No edema or cyanosis

9
Assessment/Plan

• 63 y/o AAF presenting with hypertensive crisis
  and status epilepticus leading to respiratory
  failure. The etiology of the seizures were
  unknown. Hypertensive encephalopathy vs uremia.
• Neuro- Continuous EEG monitoring and control of
  seizure activity
• Resp- Wean Vent as tolerated
• CVS- HTN control
• Renal- HD
• ID- Pan Cx

10
Hospital Course

• HD 1-4- Intermittent seizure episodes continue
  despite being on propofol, dilantin and depakote.
  BP is labile and now requires sporadic use of
  Levophed (secondary to high sedation). Vent
  dependence decreasing (tolerating CPAP 40 FiO2)
• HD 5- 1900- Extubated
• HD 5- 2100- Reintubated (patient found to be
  stridorous and obtunded). BP 220/120 HR 100
• HD 6- Extubated and reintubated after patient
  became stridorous quickly after extubation

11
Hospital Course

• HD 6- Blood Cx and Cath tip Cx- Enterococcus-
  Unasyn started
• HD 8- Tracheostomy and PEG placement performed

12
Hospital Course

• HD 9- Pt stable and transferred to the floor
• HD10- Respiratory distress with inability to
  pass suction catheter. Tracheostomy found not be
  in place.

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14
Hospital Course

• HD 10 (cont.)- Tracheostomy tube replaced by
  Endotracheal tube. Pt. severely acidotic (pH 6.9)
• HD 10-11- Patient transferred back to ICU.
  Palpable pulse with inability to get BP or Pulse
  Ox. HR began to drop, 0.5mg IV Atropine given,
  pressors started. HR up to 130 bpm, but begins
  to drop again precipitously. BP also droping.
  Eventually CPR is started. Code called at 0715.

15
Literature

• Roppolo LP, Walters K. Airway management in
  neurological emergencies. Neurocrit Care.
  20041(4)405-14.
• Chin RF, Verhulst L, Neville BG, Peters MJ, Scott
  RC. Inappropriate emergency management of status
  epilepticus in children contributes to need for
  intensive care.J Neurol Neurosurg Psychiatry.
  2004 Nov75(11)1584-8.
• Carvalho M, Mayer JR Jr., Rochs MR, Kruger R,
  Titton JA. Generalized status epilepticus
  associated with massive pulmonary aspiration and
  transient central diabetes insipidus case
  report.Arq Neuropsiquiatr. 2000
  Sep58(3B)913-5.
• Grant IS, Andrews PJ. ABC of intensive care
  neurological support.BMJ. 1999 Jul
  10319(7202)110-3.