Interactive Student Case: "Found Down"

[SERENITY NOW]

You, the intrepid new grad PA, arrive for another busy ED shift.  You are working in the main ED, and EMS comes in bringing in a 70 something year old man from assisted living facility who is awake on the stretcher.  EMS gives the report,  "This is a tough one.  The facility wasn't able to give much of a report, and the patient hasn't said a word to us.  The paperwork they gave us said that the patient only has a PMH of HTN, DM, MI and he is usually functional.  The staff nurse found him passed out laying on the ground in the middle of his room and his extremities were shaking for a few seconds before he woke back up.  Since waking up, he has remained nonverbal which is not typical for him, but they didn't give us any further details."  

 

Your team mobilizes without you needing to say a word and things happen in parallel while EMS is giving the report... 

-Vitals: 194 / 104.  HR 98.  RR 12.  O2 94%  Temp 99 oral.  

-peripheral line placed

-placed on cardiac monitor: normal sinus rhythm

 

The team now looks to you, "What's the plan, boss?" 

Do you have a systematic approach for this type of situation?  (hint, you should!)  What is your approach?  I will provide details/answers to fit whatever approach you put forth to make this interactive as we walk through the case.  

 

(This is based on a case I had in residency a couple of years back.)

[EMEDPA]

cool case! thanks for the presentation!

[pastudentw]

I'll give this one a try and we will see where it goes!

First and foremost- ABC's. Sounds like things are in tact based on vitals but I need lung sounds, chest rise, visual exam of the skin/extremities, pulses.

I already have some differentials popping in my head so..

finger stick blood sugar (surprised EMS wouldn't do this en route?)

EKG- looking for signs of electrolyte abnormalities and ischemic changes

CMP as well

I'm ok with his BP as it is, unless I start to see signs of organ failure or a bleed.

He could also  be in a postictal state but finding the cause of the proposed seizure needs a work up. I would start with the above initially. If he continues to be stable, he would need a head CT due to possible head trauma, unwitnessed fall and seizure.

Hopefully this is a good start!

 

[SERENITY NOW]

Great thoughts @pastudentw !  

 

For this patient, ABCs are intact, Accucheck 198.  Lung sounds clear, chest rise present, skin / extremity exam is without signs of infection, pulses symmetric.  I'm going to wait on giving workup results at this point until we get a little more feedback.

 

We make a quick determination at this point, 2 minutes into his evaluation... sick or not sick?   Stable or unstable?  He appears to be sick, but stable.   

Acutely altered elderly patients often have very bad things going on.  This is not the time to hold back on ordering tests.  After the ABCs / basics, its common practice to 'shotgun a bunch of tests while you continue to try to sort things out at bedside.  The challenging thing is that these patients often need a lot of orders, and it can be easy to forget important ones.  I find it helpful to make note of "unique features" that pop up throughout the case that each have their own workup considerations, and be sure to address all of them (I use check boxes on my patient note sheet).  This way I am systematically going through a checklist and its much harder to miss important parts of the eval and orders.  This case has several unique features...

What evaluation (HnP) might you do, and what orders might you include for each of the following features in this case?

-found down patient

-syncope vs seizure

-altered mental status (AMS)

-neuro eval (a subheading under AMS) - bonus question:  pretend you are at bedside and ask yourself specifically how would you go about getting a neuro exam on a nonverbal and altered patient?

-vasculopathic patient

 

Answers don't have to be perfect!  We are just discussing some points as we work through this case.  I'm hoping to provide a little bit of the framework as we go.    

 

[karebear12892]

2nd year PA student here. I'll procrastinate my OB/GYN studying by adding in my two cents.

History:

-Was this incident witnessed by anyone at the facility? Anyone know how long he was down? Last known well time? 

-Medication list? History of MI/HTN = good chance he's on a beta blocker, in which case a HR of 98 may be falsely reassuring. Would also be curious to know if he is on anticoagulants given his history. Probably not on anticonvulsants w/ no PMHx of seizures but I'd double check. Also make sure he isn't on anything else that would warrant measuring a serum level (ex: Digoxin). 

-Any family, friends, neighbors, staff, etc. present to provide additional history? Similar episodes in the past? Complaints of anything earlier in the day, prior to the incident? Any new medications or changes in his medications? Recent surgery? History of alcohol/substance abuse? 

PE:

ABC's intact as described above. Some things I'd be looking for on secondary survey along w/ differentials, specifically based on what we know so far:

-HEENT: pupil size/reactivity/nystagmus (toxic ingestion? bleed?), Battle's sign/raccoon eyes/hemotympanum (ICH?), other head trauma, tongue laceration (if present, midline or lateral? Helpful in distinguishing syncope vs. seizure...if he has teeth). Oral mucosa = dry or moist? 

-Neck: Posterior midline tenderness (C-spine injury from fall?), nuchal rigidity (meningitis?), carotid bruits (stroke?)

-Cardiac:  NSR on the monitor is reassuring but cardiac arrhythmia is always on the differential in syncope (if that's what occurred). 

-Lungs: You mentioned lungs sounded clear, SpO2 94%....always a concern for pneumonia/influenza in elderly patient w/ AMS...would risk stratify for PE with Wells. Recent literature suggests PE causes syncope more than we realize. He cannot be PERC'd. 

-GI/GU: Check bowel sounds, hepatosplenomegaly (could he be encephalopathic?), tenderness (looking for non-verbal pain cues....specifically CVA/suprapubic tenderness; always consider UTI in elderly patient w/ AMS), evidence of bladder/bowel incontinence (also helpful in distinguishing seizure vs. syncope), check hemoccult (could be anemic from GI bleed, would also get a rectal temp) 

-Skin/Extremities: Looking for rash, capillary refill/skin tenting (hydration status?), assess ROM (trauma from fall?), asterixis (again looking for encephalopathy), track marks (unlikely in this patient but hey you never know), jaundice, assess calf circumference/lower extremity edema. 

-Neuro: GCS? Posturing? CN function? Reflexes? Gaze/EOM? Facial droop? Drift/focal extremity weakness? Hemiparesis? He may be nonverbal but his ability to follow simple commands and shake/nod his head yes or no dictates a large part of how the rest of the neuro exam will go. 

Plan:

There's a good deal of overlap in terms of what I'd order for AMS/syncope/seizure in an elderly patient - as you mentioned, this would not be the time to be shy with ordering tests. 

My top priority in this patient following ABC's is obtaining a non-contrast head CT.  My index of suspicion for ICH at this point is high. 

I agree with the above suggestions of EKG (electrolyte abnormality could cause a seizure, arrhythmia could cause syncope). Would obtain old EKG for comparison if available - with his history, it will almost certainly be abnormal. I also agree that we should not precipitously lower his BP and risk cerebral hypoperfusion in the event that he is having an ischemic stroke. He could be postictal but in this patient, I'd consider that to be a diagnosis of exclusion. 

May suggest additional diagnostics based on PE findings but I'd probably start with (in addition to the above) CBC, magnesium/phosphate (low levels may cause seizure), troponin, CPK (we don't know how long he was down....rhabdo?), lactic acid, D-Dimer, blood/urine cultures, influenza, urinalysis, chest x-ray, UDS, EtOH level, coags, type & screen, and CT neck (he cannot be cleared via NEXUS criteria). 

Gonna hold off on suggesting interventions for now, pending PE findings....but I would elevate the head of the bed to reduce ICP and keep him on a cardiac monitor. 

Great case. Thanks for sharing! 

[ohiovolffemtp]

I like what Karebear had to say.  At this patient's age, he may not mount a fever, but his temp is elevated.  He's close to tachy.  Sepsis is very much in the differential.  Would definitely begin rehydration, probably would start Ofirmev.  While it's doubtful, is there a time last normal?  Any lateralizing deficits?  Any external signs of trauma?  From EMS: any signs of fall such as disturbed furniture?  Did they bring the grocery bag containing all of the patient's meds.  Depending on time of year, is CO poisoning a concern?

[SERENITY NOW]

On August 4, 2018 at 10:54 AM, karebear12892 said:

2nd year PA student here. I'll procrastinate my OB/GYN studying by adding in my two cents.

History:

-Was this incident witnessed by anyone at the facility? Anyone know how long he was down? Last known well time?  Excellent!  These are critical questions, especially last known well time, and often these are not answered in their (pathetic) "reports" from their facilities, so we didn't have this information.

-Medication list? History of MI/HTN = good chance he's on a beta blocker (good thing to look out for - he is not on them), in which case a HR of 98 may be falsely reassuring. Would also be curious to know if he is on anticoagulants given his history (he is not, but also important). Probably not on anticonvulsants w/ no PMHx of seizures but I'd double check. Also make sure he isn't on anything else that would warrant measuring a serum level (ex: Digoxin). 

-Any family, friends, neighbors, staff, etc. present to provide additional history? Similar episodes in the past? Complaints of anything earlier in the day, prior to the incident? Any new medications or changes in his medications? Recent surgery? History of alcohol/substance abuse?  He didn't have any family or staff with him, so we didn't have any of this information provided to us.  

PE:

ABC's intact as described above. Some things I'd be looking for on secondary survey along w/ differentials, specifically based on what we know so far:

-HEENT: pupil size/reactivity/nystagmus (toxic ingestion? bleed?), Battle's sign/raccoon eyes/hemotympanum (ICH?), other head trauma, tongue laceration (if present, midline or lateral? Helpful in distinguishing syncope vs. seizure...if he has teeth). Oral mucosa = dry or moist?  Excellent thoughts.  he had normal pupil exam, no nystagmus, was disheveled but no obvious signs of trauma, no secondary signs of seizure.  

-Neck: Posterior midline tenderness (C-spine injury from fall?), nuchal rigidity (meningitis?), carotid bruits (stroke?)  none present

 -Cardiac:  NSR on the monitor is reassuring but cardiac arrhythmia is always on the differential in syncope (if that's what occurred). 

-Lungs: You mentioned lungs sounded clear, SpO2 94%....always a concern for pneumonia/influenza in elderly patient w/ AMS...would risk stratify for PE with Wells. Recent literature suggests PE causes syncope more than we realize. He cannot be PERC'd.  definitely always think infection in altered elderly.  the PE study you are referring to was terribly done - we had a journal club on it in residency and the majority of the EM community has agreed.  Consider PE low on ddx but don't stress about it if vitals are relatively normal.  

-GI/GU: Check bowel sounds, hepatosplenomegaly (could he be encephalopathic?), tenderness (looking for non-verbal pain cues....specifically CVA/suprapubic tenderness; always consider UTI in elderly patient w/ AMS), evidence of bladder/bowel incontinence (also helpful in distinguishing seizure vs. syncope), check hemoccult (could be anemic from GI bleed, would also get a rectal temp)  -- great idea with rectal temp - it came back afebrile.  remainder of this exam was normal.  heme neg.

-Skin/Extremities: Looking for rash, capillary refill/skin tenting (hydration status?), assess ROM (trauma from fall?), asterixis (again looking for encephalopathy), track marks (unlikely in this patient but hey you never know), jaundice, assess calf circumference/lower extremity edema. normal exam here.  

-Neuro: GCS? Posturing? CN function? Reflexes? Gaze/EOM? Facial droop? Drift/focal extremity weakness? Hemiparesis? He may be nonverbal but his ability to follow simple commands and shake/nod his head yes or no dictates a large part of how the rest of the neuro exam will go.   Great approach!  

Plan:

My top priority in this patient following ABC's is obtaining a non-contrast head CT.  My index of suspicion for ICH at this point is high. 

I agree with the above suggestions of EKG (electrolyte abnormality could cause a seizure, arrhythmia could cause syncope). Would obtain old EKG for comparison if available - with his history, it will almost certainly be abnormal. I also agree that we should not precipitously lower his BP and risk cerebral hypoperfusion in the event that he is having an ischemic stroke. He could be postictal but in this patient, I'd consider that to be a diagnosis of exclusion. 

May suggest additional diagnostics based on PE findings but I'd probably start with (in addition to the above) CBC, magnesium/phosphate (low levels may cause seizure), troponin, CPK (we don't know how long he was down....rhabdo?), lactic acid, D-Dimer, blood/urine cultures, influenza, urinalysis, chest x-ray, UDS, EtOH level, coags, type & screen, and CT neck (he cannot be cleared via NEXUS criteria). 

All are very good thoughts!  Nice work!

 

So, the neuro exam can be challenging on these altered patients.  After all, the neuro exam we learn in school is geared towards the patients who are awake, talking, and essentially interacting normally.... aka the type of patient who probably doesn't even need a neuro exam to begin with.  Be ready to apply the neuro exam to all sorts of patients, from altered to unconscious.  

His neuro exam:  overall alertness - he is awake and seems to be looking around purposefully.  You try to assess some cortical function by asking basic questions with nodding yes and no - he is able to nod his head appropriately, but for some reason he is only answering your questions and not to the nurses who are asking him questions on the other side of the bed (why might this be?  And how could you confirm your suspicion?).  You assess sensation - he can nod his head that he does feel you touching him on all extremities.  You assess motor function - he is only moving his L arm and leg - his R upper and lower extremities are flaccid.   He does not have an appreciable facial droop.

 

At this point, your concern is clear --- this is a suspected CVA until proven otherwise, and time is of the essence.  You call over to CT scan to get them ready and you try to get a quick NIHSS but encounter your first issue... how do you document an NIHSS on a patient like this who is nonverbal and unable to be tested for several of the areas of the test? (he cannot answer LOC / orientation questions, visual loss questions, nor extinction). Do you omit the sections that can't be tested or count them towards the total points?  

You also wonder to yourself, should I be calling a "code neuro" or not?  (A "code neuro" is what is called over loudspeaker of hospital for those who are tpa candidates to mobilize a large team to expedite workup, neurology consultation, and tpa administration)?  How do you make that determination?  What are the critical things you need to know when dealing with a neuro / stroke case?  How would you go about getting this information in this case given that the patient is nonverbal?  

And last food for thought, which of you would order a non contrast head CT vs a CT angio head / neck, and why?  

[EnterobacterJim]

I’m only a summer semester in so far, but let me take a crack at that last part...

If this was me right now, I would attempt all areas of the NIHSS and count the points for what couldn’t be completed. Also document which sections those were. It’s essentially a “loss” of function if he can’t do it in an affected state even with an unknown (?) baseline. 

I’m thinking a code neuro is appropriate here since we are assuming CVA and moving in that direction. At any rate it doesn’t hurt to have more resources. We would definitely want last normal if possible. It would be nice to get as much history as possible to rule in/out tpa... as well as figure out a baseline to monitor changes/worsening. We can try to get yes/no history questions. Maybe a medication list to see if he’s on anticoags after the MI for example.

If the radiologist is comfortable reading it, I would like the CT without contrast as I’m worried about his kidneys given age, HTN, and unknown control of DM.

[fishbum]

I’m not great at localizing infarcts, but PE suggests left MCA stroke. I understand that hemispatial neglect is more common in right MCA infarct, but not impossible with left.

I’m pretty sure the NIHSS form specifies that the aphasic pt gets the full score counted unless he’s intubated, bandaged up, etc. 

Important stuff to know are time last normal, is he on anti-coagulants, recent major surgery/trauma,etc. These are potential tpa contraindications (seizure at onset might be also). 

CT is looking for blood to r/o hemorrhagic stroke, non-contrast head CT is the most sensitive test to do that acutely. 

Activate code stroke or neuro or whatever it’s called at the hospital. Labetalol is also a good idea here (current BP is contraindication for tpa, and BP goals for SAH and ICH are much lower than current). 

[SERENITY NOW]

Great answers!  I'm sure if you asked 5 different docs / PAs you'd get 5 different perspectives on topics like these.  My perspective is the following (and I'm not even sure if it is 100% concordant with the book answers).... if I don't have a definitive last seen normal time, I don't know if a code neuro is appropriate, which is why it is part of the critical information you must have before calling the code neuro.  In this case, we had our nurse call the living facility who had to track down the CNA who finally told us that this patient's last seen normal was several hours ago (over 6 hours ago).  With this new information, we did not call a code neuro but instead just called down to CT to get him expedited.  

A non contrast head CT is always going to be a safe answer in acute stroke sx workup.  You can't go wrong with it.  However, many stroke neurologists and ER providers are switching to CT angio, especially for NIHSS over 8, since its protocol still includes a nonctontrast head CT eval AND it can identify high grade occlusions amenable to IR intervention regardless of the time of onset of symptoms.  There is new research showing that our imaging modalities (CT and MR perfusion scans) can be more helpful at determining the potential benefit from intervention than the time of onset can.  There have been reports of improvement up to 24 hours from time of onset!  So, you proceed to order a CT angio on this patient, who had a very high NIHSS and prolonged sx duration, nor any hx of renal problems.  

 

So, everything has been stable, CT tech says that they cleared their table and are ready for your patient.  The nursing team starts wheeling them down the hallway and you go to see your next patient, when..... "Hey its Lynn (the nurse), our patient was just about to be transferred to the CT table and he started vomiting all over the place.  Is it okay if we just try to get this CTA quick and get him back right after?"

 

How do you proceed?  

 

[karebear12892]

All right, I'll give it a go: 

1. Reassess ABC's. Given this patient's neurological status, I'm concerned about his ability to protect his airway and prevent aspiration. I would have a low threshold for intubating this patient while keeping his head elevated as much as possible due to likely increased ICP. Recheck cardiac monitor - does he need BP control at this point? 

2. Reassess GCS. Is he still able to answer questions? Any seizure activity? Posturing? Change in his pupils?

3. Need to control his vomiting so that we can obtain stat head CT. If his vomiting is indeed due to increased ICP, then IV steroids should help, as well as IV Zofran or Reglan (not sure if one over the other would be preferred in this scenario). Based on the abrupt change in his condition, I would consider obtaining a non-contrast CT of his head instead of the CTA for now since it can be done more quickly.

4. Do we have any labs back? Depending on his sodium level/hydration status, he may be a candidate for Mannitol.  

 

[EMEDPA]

regarding selection of study- all the places I work at are small/low volume, so for r/o stroke I typically follow the pt to CT. I order noncontrast head CT and CTA head/neck, but cancel it if I see a big bleed or huge brain tumor or something on the initial noncontrast study. 

[husky1528]

@EMEDPA just left working in an ED where they began to implement NIHSS requirements for CTA's of the head in neck in "Code Neuros". Had to be higher than a 6 in order to even get the radiologist to approve or read it. Anybody else ever heard of anything like this? 

[EMEDPA]

9 minutes ago, husky1528 said:

@EMEDPA just left working in an ED where they began to implement NIHSS requirements for CTA's of the head in neck in "Code Neuros". Had to be higher than a 6 in order to even get the radiologist to approve or read it. Anybody else ever heard of anything like this? 

nope, everywhere I work I don't need approval for any study. I often get them for TIAs (or CT head with plus b/l carotid u/s if younger or finances a major issue in the setting of no ongoing sx). 

[SERENITY NOW]

10 hours ago, karebear12892 said:

All right, I'll give it a go: 

1. Reassess ABC's. Given this patient's neurological status, I'm concerned about his ability to protect his airway and prevent aspiration. I would have a low threshold for intubating this patient while keeping his head elevated as much as possible due to likely increased ICP. Recheck cardiac monitor - does he need BP control at this point? 

2. Reassess GCS. Is he still able to answer questions? Any seizure activity? Posturing? Change in his pupils?

3. Need to control his vomiting so that we can obtain stat head CT. If his vomiting is indeed due to increased ICP, then IV steroids should help, as well as IV Zofran or Reglan (not sure if one over the other would be preferred in this scenario). Based on the abrupt change in his condition, I would consider obtaining a non-contrast CT of his head instead of the CTA for now since it can be done more quickly.

4. Do we have any labs back? Depending on his sodium level/hydration status, he may be a candidate for Mannitol.  

 

Right on the money!  CT is where unstable patients go to die... must have ABCs covered before going to CT, and an altered stroke patient uncontrollably vomiting should have their airway taken.  

 

So, you tell the nurses to bring the patient back.  He seems to be decompensating... now his eyes aren't open, and he is not following any commands.  Sternal rub gets him to stir slightly but overall you are very concerned.  You perform another critical evaluation piece: scan the chart for code status and advance directives!  He is full code and okay with intubation / mechanical ventilation; nursing staff calls family in.   

Very good thoughts regarding ICP... assume the worst and choose RSI medications that will not raise ICP (which meds would be good choices and which bad choices?).  You successfully intubate him, confirm placement CXR, and make sure everything is stable post intubation, because often unstable patients can crump after intubation (hence the saying "resuscitate before you intubate").  

 

Luckily he is stable post intubation... you whisk him off to CT scan and your concerns come true... a large subdural hemorrhage with midline shift.  We have our diagnosis, now what do you do from here?  How do you manage his intracranial hemorrhage?  

 

Lab workup is starting to come back and so far looks unremarkable.  CBC wnl, platelets wnl, BMP unremarkable aside from mild hyponatremia and blood sugar 260, coags wnl.   

[LT_Oneal_PAC]

4 hours ago, SERENITY NOW said:

Right on the money!  CT is where unstable patients go to die... must have ABCs covered before going to CT, and an altered stroke patient uncontrollably vomiting should have their airway taken.  

 

So, you tell the nurses to bring the patient back.  He seems to be decompensating... now his eyes aren't open, and he is not following any commands.  Sternal rub gets him to stir slightly but overall you are very concerned.  You perform another critical evaluation piece: scan the chart for code status and advance directives!  He is full code and okay with intubation / mechanical ventilation; nursing staff calls family in.   

Very good thoughts regarding ICP... assume the worst and choose RSI medications that will not raise ICP (which meds would be good choices and which bad choices?).  You successfully intubate him, confirm placement CXR, and make sure everything is stable post intubation, because often unstable patients can crump after intubation (hence the saying "resuscitate before you intubate").  

 

Luckily he is stable post intubation... you whisk him off to CT scan and your concerns come true... a large subdural hemorrhage with midline shift.  We have our diagnosis, now what do you do from here?  How do you manage his intracranial hemorrhage?  

 

Lab workup is starting to come back and so far looks unremarkable.  CBC wnl, platelets wnl, BMP unremarkable aside from mild hyponatremia and blood sugar 260, coags wnl.   

Any sedative drug would work. Ketamine doesn’t raise ICP, despite dogma surrounding it. Propofol might drop his pressure too much, but in skilled hands smooth as butter. Personally dislike etomidate and one could talk about the adrenal suppression, but who knows if that is clinically significant with one dose. One could even argue putting this guy down with 10mg of versed might not be bad given he’ll need seizure prophylaxis. Personally, I’d go with propofol.

[ohiovolffemtp]

Frankly, my choices of induction and paralytic agents are largely driven by what I can get to bedside quickly - which excludes ketamine or propofol which have to come from pharmacy.  So, it's etomidate or versed, then sux or roc.

[ohiovolffemtp]

I'd probably go with phenergan as the anti-emetic since I've had patients get crazy with reglan.  It's time to start lowering the BP.  Given the pulse, I'd probably start with labetolol.  Since nowhere I work as neurosurgery I'd be checking on the availability of jet-A or diesel if it isn't available.

[SERENITY NOW]

Nice work, team.  Sorry I haven't been able to post recently but have been busy with work, but the questions were discussed just fine.  This patient ended up having ED stabilization of BP, blood sugar, head of bed, coags and we called a neurosurgery consult.  They took him to OR for a crani, was in the ICU for some time, and I believe in the end had a poor outcome.  It is very unfortunate that this was a bad outcome, but it is a case that certainly has a lot of teaching points at each step of the way, so I hope you all found it valuable as well.

If you enjoyed these cases and this format, let me know since I am happy to do more.  If you have a particular chief complaint or condition that you struggle with, let me know and I can gear future cases to those needs.  

Thanks for following along!
-SN  

[karebear12892]

Great case! Please share more of them in this format. Great way for us to learn. Thanks so much! 

[Aunt Val]

I'm a bit late seeing this but enjoyed reading through it.  Thanks, and please post more when you have the time.

[nicksadow92]

Thanks so much for this! Incredible format, and it's great to learn the process before even being in PA School yet. I work in a L1 trauma center in Detroit, so I see a lot of this and am immersed with the teaching of the cases we see with it being a teaching hospital, and it's great to see it in these forums as well. 

Please continue to post these! Following.