Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Sarah MacArthur, MD
Tuesday January 22nd, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• Ms. H is an 82 year old woman who presented
with neck pain for 4 hours.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Prior to presentation the patient was living
independently at home ambulating with a walker.
•She had engaged in careful advanced care
planning. Including:
•A) signed Health Care Proxy paperwork.
•B) signed DNR/DNI order
•C) signed advance directive stating that she did
not want mechanical life support under any
circumstances.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•On the day of admission the patient tripped and
hit her head on the wall. She developed significant
neck pain, activated EMS, and was brought to the
Bellevue Emergency Department.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History: Rheumatoid Arthritis
•Past Surgical History: none
•Social History: No tobacco/alcohol/illicits. Close
relationships with her family including her sister
and two nieces.
•Medications: None
•No Known Drug Allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Elderly woman lying in stretcher in
significant pain
•Vital Signs: T: 97.7 HR: 80 BP: 132/62 RR: 18
O2 sat: 99% on Room Air
•HEENT: Patient was in a hard cervical collar
•The remainder of the physical exam, including a
detailed neurologic exam, was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: within normal limits
•Basic Metabolic panel: within normal limits
•Hepatic panel: within normal limits
•Coagulation panel: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•CT Cervical Spine: Acute type II dens fracture
with displaced fragments.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Acute type II Dens fracture with displaced
fragments
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient was admitted to Neurology for
initial treatment with cervical collar and with
plans to discuss her case at spine conference.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• On Hospital Day 4 a Rapid Response was called.
• Chart review revealed no documented code
status and no surrogate contact information.
• The patient was intubated for hypoxic
respiratory distress and transferred to the MICU.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• In the MICU the patient had an extensive workup.
• She was extubated, and reintubated.
• The conclusion was that the patient was
repeatedly aspirating because her cervical collar
prevented her from tucking her chin and
clearing her secretions.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Concurrently the patient was discussed in spine
conference.
• Their final recommendations: conservative
management.
• Given her highly unstable fracture it was
considered imperative that the patient remain in
her cervical collar.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The MICU team was in close communication
with the family.
• They conveyed their impression that the patient
would be at continued risk of aspiration because
of a non-modifiable risk factor--her cervical
collar.
• The family, confident of the patient’s wishes,
reaffirmed the patient’s DNR/DNI and asked
that she be extubated.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• On Hospital Day 9, extubated and stable, the
patient was transferred to the medicine floors
with plans for discharge to Hospice.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• There the consulting Neurology team expressed
their strong feeling that, since a dens fracture is
neither irreversible nor terminal, the patient was
not an appropriate Hospice candidate.
• They advocated for a more assertive approach to
her care.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• On Hospital Day 13 at 7 AM the patient was
again in respiratory distress. PEA arrest
followed, and she was declared dead at 8AM.
The family was contacted and expressed thanks
for her care.
• Some provider’s had persistent concern that,
despite 2 intubations, the patient did not receive
adequate care.
• She was presented at a Neurology M&M.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• PEA arrest from hypoxic respiratory failure.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS