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



2D  ECHO:
Impression:
No REMA
Mild LVH ( 1.2 cms )
Trivial TR+/ AR+
Sclerotic AV
EF- 50 %
RVSP- 35 mmhg
Fair LV systolic function
Diastolic dysfunction +


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


Day 3

 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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