43 year old male with seizures
A 43 year old male patient came to the casuality on 18/10/21 at 8:20 pm with
C/o fever - low grade 1 episode yesterday
C/o sudden onset of involuntary movements of rt UL and LL
with frothing +, LOC lasting for 10 mins with post-icteal confusion +
PAST HISTORY:
43yr/male, unmarried, born to non-consanguineous marriage was diagnosed with poliomyelitis at age < 5 yrs , studied upto 6th standard and stopped school due to decreased attention and ? Memory
impairment , walked with support.
He attained all milestones normally.
He was given the job of taking care of cattle till his father expired around 5 yrs back.
Just before this he behaved unusually, talking to himself, wandering around, behaved aggressively for 1 week and was taken to yerragadda and was started on anti psychotics.
He was then made to stay at home, able to perform his own activities.
Patient was asymptomatic till 1 day ago, when he developed fever which was low grade, decreased on medication.
At 3:00 pm yesterday , after he finished having lunch, Pt suddenly developed one episode of Rt sided UL and LL involuntary movements with loss of consciousness for 10 mins, regained spontaneously; did not talk after that.
Following that he had 2 more episodes, each lasting for 2-3 mins, with one episode of vomiting.
He was treated outside with
inj Levipil 2g IV/ stat, catheterised and referred here.
Not a k/c/o HTN, DM
VITALS ON ADMISSION:
Temp- afebrile
Pulse- 92 bpm
BP- 140/90 mmhg
RR- 18 cpm
Spo2- 98% at RA
GRBS- 137 mg/dl
O/E:
CVS- S1 S2 +. No murmurs
RS- NVBS. No crepts
P/A- soft
CNS-
Drowsy but arousable
Speech- no response
GCS- E2 V2 M5
Pupils -NS sluggish r/n to light
Conjunctival reflex +
Corneal reflex +
Rt Lt
Tone
UL Increased N
LL. Increased N
Power
UL. 4/5. 4/5
LL. 3/5. 3/5
Reflexes
B. 2+. 2+
T. 2+. 2+
S. - 2+
A. - -
K. - -
P. ^ Mute
INVESTIGATIONS:
ECG
CHEST X-ray
MRI BRAIN
Diagnosis:
Focal seizures ( Rt side ) with secondary generalisation secondary to cortical venous sinus thrombosis
with
H/o ? Psychosis
( on anti-psychotics)
TREATMENT IN HOSPITAL:
Ryles catheterisation
Inj lorezepam 2 cc/IV/ sos
Inj mannitol 100 ml IV/TID
W/H Antipsychotics
RT feeds- 50 ml milk 2nd hourly.
Day 2:
Inj mannitol 100 ml / IV/ TID
Inj Levipil 1 gm/ IV/ BD
Inj Lorazepam 2 cc/ IV / SOS
RT feeds- 50 ml water 2nd hourly
100 ml milk 4th hourly
Inj Monocef 1g IV/ BD
inj Enoxaparin 40 mg every 12th hourly
Pt was having constant fever spikes (100-101 F) since yesterday night and GCS -3/15 . No response to deep painful stimulus. pulse rate intially was 52-58 bpm (bradycardia) for sometime. Later pt had tachycardia with pulse rate of 160-170 Bpm.(sinus tachy) .BP -160/100 mmhg
- INJ PCM 1gm was given twice and tepid sponging ,ice packs were placed. Heart rate decreased to 150 bpm.
At around 4:00 am , pt saturations started falling and spo2 -46% on RA.
Central pulse was present. But there was no spontaneous breathing .
So immediately ambu was done with high flow oxygen. Oral suctioning was done .
After adequate pre-oxygenation , pt was Intubated with 7 mm ET tube and connected to mechanical ventilator .
ACMV VC MODE : RR-14 /min ; FIO2- 100% ;
VT- 480 ml ; peep-5 cm of h20 .
Post intubation vitals : BP- 120/70 mmhg - on NA -6ml/hr
PR- 116 bpm ; regular .
SPO2-. 98% ; RR- 14
CVS -S1S2 PRESENT
RS- BAE present . b/l coarse crepts present.
post intubation ABG :
ABG : ph - 7.18
pco2- 59
po2- 51
sO2- 73.8 %
hco3- 18.3
POST INTUBATION X ray
Patient attenders were counselled regarding organ donation and its importance.
Main concerns from pt side ( as discussed with his nephew and own sister ).
1) What is the exact procedure of organ donation and will it happen now ? bcoz we have to leave tomorrow morning again .
A) We told there is a protocol before harvesting organs , we need to first declare pt brain dead , and it has to be certified by 2 different physicians including a neuro-physician. So it ll take some time.
And i also explained pt pulse is very feeble and bp is not recordable .Pt is on inotropes . So Proper perfusion is also required to organs to be healthy.
They agreed for it.
2) Another query was will pt body smell after organ harvestment ? Can they take home like that ?
A) I told no body will be handed over after stitching and it wont smell. They ll use formalin. And they can take home.
3) Will eyeballs be removed and face looks dysmorphic ?
I explained only cornea will be taken, and it wont look abnormal.
They have financial issues and are asking to send body to their home after the procedure , as they cant afford for ambulance again , which i told , i ll let them know soon.
Basically sir attenders , want to get it done fast and take pt home for rituals to be performed. They've signed on consent form for organ donation in case sheet.
DAY 4:
ICU BED 6 :
S - Pt comatose . GCS -3/15 .
There was hypothermia noted till yesterday night (94-95 F)
Blankets and warming was done . Temp increased to 98 F early morning.
BRAIN STEM Reflexes performed.( By Dr Hareen sir and signed under duty medical officer ).
NO Corneal ,conjunctival ,gag reflex .
Caloric test was performed . No eye movements noted.
APNEA TEST was performed .
After preoxygenation for 5 min with ambu bag with high flow oxygen and later pt was connected to T - piece and oxygen and observed for spontaneous respiration. His saturations decreased from 98- 85 % .
ABG before apnea test :
ph- 7.28
pc02- 36.6
po2- 69.1
so2-. 91.7% hco3- 16.9
ABG after apnea test :
Ph-. 7.122 pco2-.59.8 po2-.37 so2-58.4. hco3-. 18.7
After apnea test ,there is documented evidence of fall in pao2 and pco2 rise.
O - Pt blood pressure improved .
BP-160/100 mmhg ( on Nor ad -12 ml/hr
Vaospressin 2ml/hr and dobutamine tapered and stopped overnight after careful monitoring of BP)
PR - 101 bpm
SPO2- 99%
TEMP- 97.3 F
Pt is in mechanical ventilator ACMV - VC mode .
RR-18/min ; VT -460 ml ; Peep-7 cm of h2o
Fio2- 55 % .
A - Seizures secondary to
CSVT ( superior saggital venous sinus ) with hemorragic venous infarcts in bilateral frontal lobes
k/c/o Psychosis ( on anti-pyschotics ).
Type 2 resp failure
?? Brain dead .
PLAN - To document brain dead and plan for organ donation.
DAY 5:
S:
E1 V1 M1
Pupils dilated. Not reacting to light
Corneal reflex -
Conjunctival reflex -
O:
Afebrile
BP-110/ 80 mmhg
PR- 115 bpm, Regular
CVS- S1 S2 +. No murmurs
RS- NVBS +. Decreased breath sounds in right ISA
P/A- Distended, soft
CNS-Pupils dilated. Not reacting to light
Corneal reflex -ve
Conjunctival reflex -ve
Plantar mute
Doll’s eye -ve
Tone- decreased in all 4 limbs
Patient on inj. NORAD- 8ml/hr
Inj. VASO- 3 ml/ hr
Inj. DOBO- 30 drops/ min
A:
Cortical sinus venous thrombosis ( superior sagital venous sinus)
Focal seizures with secondary generalisation secondary to ? Infection ? Meningitis with
Type II respiratory failure with
K/c/o psychosis on antipsychotics
Pt declared brain dead
P:
Head end elevation upto 30 *
Air water bed
INJ levipil 50 mg iv/bd
INJ Mannitol 100 g iv /bd
INJ Vancomycin 500 mg iv/bd
INJ meropenam 500 mg iv/bd
INJ Clexane 60 mg / s/c BD
RT feeds 50 ml water hrly
100 ml milk hrly
IVF NS , RL @ 75 ml/ hr
Bp /PR / Spo2 charting hrly
Planning for organ donation
Patient lama on 22/10/21 at 3:30 pm
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