Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Abnormal behaviour, Acute respiratory distress syndrome, Affect lability, Brain herniation, Brain injury
Clinical narrative: 48 y/o female with pmh of HTN, HLD, DM2 and bipolar disorder, transferred to ICU from the psychiatric until after cardiac arrest.  The patient was originally admitted on 5/22 for evaluation of bizarre behavior. She was noted to have flight of ideas, emotional instability and multiple attempts to leave the room naked. She was admitted to the floor there with behavioral health consulted for evaluation. She was then transferred to another  unit on 5/27/21 for additional management, with a plan for a 90 day inpatient hold.  While in the unit she was managed with a medication regimen including Thorazine, Lithium and Abilify.  Medicine was consulted for management of hypertension, and Ob-Gyn was following for abnormal vaginal bleeding with work-up unable to be completed due to her mental status.  ECT treatments were also started this week on 6/23, with the patient receiving her second ECT treatment this afternoon.  From review of the pre-procedure note, the planned induction was with etomidate, succinylcholine, glycopyrrolate, and Brevitol (methohexital, barbiturate class); the actual MAR is not up to date with her procedural medications at the time of admission.  Post treatment, the patient was noted to be conversive and in her normal state of health.  This evening, nursing staff heard a loud noise from the patient's room around 1630. Upon arrival, they found her down, unresponsive and without a pulse. An ACT was called  and CPR was initiated for a duration of approximately 30 minutes. Reportedly the AED display showed asystole, followed by PEA.  She received a reported five rounds of epinephrine, one dose of bicarbonate, and one dose of calcium during the event.  The patient was intubated during the code with a large amount of gastric contents present, concerning for aspiration.  A right ankle IO was placed due to significant difficulty securing access elsewhere.  ROSC was obtained with a junctional rhythm, and the patient was transferred for further management.      On arrival the patient is non-responsive without any sedation running.  She became hypotensive by arrival to the ICU requiring norepinephrine.  On later inspection of her IO, there was suspicion for infiltration of fluids and medications around her right ankle.  She has had significant secretions into her ETT since transfer.   HPI as noted above.  ICU course notable for hypoxic respiratory failure with ARDS likely from lung injury from cardiac arrest.  She subsequently developed shock and required vasopressors.  Initially the patient was noted to have brainstem reflexes, however on 6/25 the patient had an exam change with no spontaneous breaths and pupils fixed and dilated.  The initial head CT following arrest was performed which showed diffuse cerebral edema with effacement of the sulci and gray and white matter differentiation consistent with severe anoxic brain injury. There was diminished ventricular size with complete effacement of the fourth ventricle and tonsillar herniation from mass effect.  Neurology was consulted.     The patient remained on vasopressor and mechanical ventilator support. A NM scan was performed to evaluate cerebral blood flow showed absence of effective cerebral perfusion.  Neurology performed an exam and the patient was pronounced deceased at 1802 on 6/27/21 a doctor.   The family was informed of the results. After discussion with family, the patient was removed from mechanical ventilator support and vasoactive medications discontinued with the family at beside.