Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Blood glucose increased, Brain herniation, Brain stem syndrome, Bundle branch block left, COVID-19
Clinical narrative: Deceased (1.4.22); Hospitalized/ED (1.4.22); COVID-19 positive (1.4.22); Fully vaccinated - pfizer x3 ED Note: CHIEF COMPLAINT: CARDIAC ARREST   Assessment/Plan    DIAGNOSIS at time of disposition: 1. Acute cerebellar hemorrhage  2. Cardiac arrest    ED Disposition    ED Disposition   Expired  Objective     MEDICAL DECISION MAKING: This patient was signed out to me pending family discussion for goals of care.  The family spoke with the neurosurgical team regarding prognosis as well as us.  The mother and uncle were bedside and decided to make the patient comfort care only.  We proceeded with extubation and stopped blood pressure supporting medication.  The patient ultimately passed @ 2125.  Medications etomidate (AMIDATE) injection (30 mg Intravenous Given 1/4/22 1734) EPINEPHrine 1 mg/10mL syringe (1 mg Intravenous Given 1/4/22 1808) sodium bicarbonate 8.4 % injection (50 mEq Intravenous Given 1/4/22 1751) rocuronium (ZEMURON) injection (100 mg Intravenous Given 1/4/22 1734) EPINEPHrine (ADRENALIN) 5 mg in NS 0.9% 250 mL (0.02 mg/mL) infusion premix (0 mcg/kg/min × 111 kg Intravenous Stopped 1/4/22 2110) sodium bicarbonate 8.4 % injection CONFIRM DOSE - Pyxis Override Pull - (has no administration in time range) iopamidol (ISOVUE-370) 76 % injection 100 mL (has no administration in time range) sodium chloride 0.9% for CT injector flush 100 mL (has no administration in time range) sodium chloride flush 0.9 % syringe 10 mL (has no administration in time range) lidocaine (PF) 1 % injection CONFIRM DOSE - Pyxis Override Pull - (has no administration in time range) sodium chloride 0.9 % infusion CONFIRM DOSE - Pyxis Override Pull - (has no administration in time range) fentaNYL (SUBLIMAZE) injection 100 mcg (has no administration in time range) LORazepam (ATIVAN) injection 2 mg (has no administration in time range) anti-inhibitor coagulant complex (FEIBA) injection 5,044 Units (5,044 Units Intravenous Given 1/4/22 1829)   New Prescriptions   No new medications prescribed this visit. MD    MRN:  CSN:       ED Provider Notes MD ? : Emergency Medicine MD at 1/5/2022 10:550AM Cosigned by: 1/5/2022 10:50 AM  Procedure Orders 1. Insert Arterial Line ordered by MD  2. Intubation ordered by MD Signed by MD at 1/5/2022 10:50 AM ATTENDING NOTE: I have personally taken a history from and examined this patient and directed the care given in conjunction with the documenting resident. Unless otherwise indicated in a supplemental note, I agree with the resident's assessment and documentation. I was physically present for the key elements of all procedures done by those residents under my supervision.    Emergency Department Attending Physician Addendum   Date of service: 1/4/2022   I cared for this patient with the Resident. Please see their note for the additional details regarding this patient's encounter.    Brief history, exam and Medical Decision Making: Patient seen in conjunction with the resident.  Patient arrives as opposed to rest and was seen on arrival in the Trauma Bay.  Did require resuscitation and several rounds of CPR.  The airway was changed over to a conventional ET tube.  Patient underwent head CT which showed a cerebellar hemorrhage with compression of the brainstem.  Also noted to have blown pupil on the CT scanner.  Blood pressure was quite labile, so an art line was established.  Stat neurosurgery consult obtained.  Anticoagulation reversed.  Family contacted and informed of grave diagnosis and prognosis, who ventrally opted for extubation and comfort care.   Critical Care Time: Critical Care time was required due to the life threatening nature of this patient's condition and I spent 95 minutes performing critical care. This excludes any procedures done during this time.    Expand All Collapse All 01/04/2022   CHIEF COMPLAINT: CARDIAC ARREST  Assessment/Plan  DIAGNOSIS at time of disposition:  1. Acute cerebellar hemorrhage  2. Cardiac arrest   Discharge Medication List as of 1/4/2022 11:13 PM  ED Disposition    ED Disposition   Expired  MEDICAL DECISION MAKING: Supervising Physician: Dr.   ED Course as of 01/04/22 2344 Tue Jan 04, 2022 1911 62yo male with witnessed arrest and immediate CPR. Initial rhythm PEA, no shocks given. No meds given prior to arrival per EMS. On arrival, central pulses are palpable.  He has a GCS of 3 with nonreactive pupils.  Patient was intubated for airway protection.  Initially, main concern was for a massive PE given reports of a respiratory arrest and patient's complaint of immediate preceding shortness of breath.  EKG had been obtained and showed a LBBB without signs of ischemia using Sgarbossa criteria. LBBB is not new today. Plan is to go to CT.  Will also obtain CT head, abdomen, and pelvis given patient's history of AAA.  Prior to going to CT, patient had a 2nd cardiac arrest with 2 minutes of CPR and subsequent ROSC.  1916 Patient was started on epinephrine drip and then transported to CT.  CT head was obtained which showed a cerebellar hemorrhage.  Before additional imaging could be obtained, patient had a 3rd arrest while in CT, with given another dose of epinephrine, and underwent 1 round of CPR before ROSC.  Additional imaging was forgone due to his instability and patient was returned to the resuscitation Bay where an arterial line was placed for closer blood pressure management. FEIBA was ordered for emergent reversal of his Eliquis. Neurosurgery was consulted and Dr. evaluated the patient at bedside.  Patient's right pupil is now blown.  GCS remains 3.  According to Neurosurgery, operative intervention would be futile at this point.  1918 He began requiring increasing doses of epinephrine and was started on a norepinephrine drip as well. BP cuff readings were extremely labile and deemed unreliable, therefore a femoral arterial line was placed as below.   2339 I spoke with MICU and NSICU intensivists and patient was accepted to the NSICU. At this time, next of kin (mother) was not yet at bedside. Uncle is at bedside but does not have decision-making capacity for the patient.  2340 Mother and stepfather at bedside and updated. Mother states that patient has expressed in the past that he does not want to be on life support. Unless there is reasonable expectation of meaningful neurologic recovery, she wishes to pursue comfort care measures. I spoke with neurointensive care NPP who will also come speak to the family regarding prognosis.  2341 Following these discussions, all family at bedside is in agreement to proceed with comfort care and palliative extubation. Patient was extubated and vasopressors were stopped. He was pronounced dead at 2125. I notified ME Dr. who stated that this will not be an autopsy case and the patient's body was released to the funeral home of family's choosing.    ED Course User Index MD  Blood Pressure Screening: Based on last blood pressure taken in the ED of (!) 0/0, HTN (>/=140/90), recommend follow up with PCP within 1 month.  Medications EPINEPHrine (ADRENALIN) 5 mg in NS 0.9% 250 mL (0.02 mg/mL) infusion premix (0 mcg/kg/min × 111 kg Intravenous Stopped 1/4/22 2110) sodium bicarbonate 8.4 % injection CONFIRM DOSE - Pyxis Override Pull - (has no administration in time range) iopamidol (ISOVUE-370) 76 % injection 100 mL (has no administration in time range) sodium chloride 0.9% for CT injector flush 100 mL (has no administration in time range) sodium chloride flush 0.9 % syringe 10 mL (has no administration in time range) lidocaine (PF) 1 % injection CONFIRM DOSE - Pyxis Override Pull - (has no administration in time range) sodium chloride 0.9 % infusion CONFIRM DOSE - Pyxis Override Pull - (has no administration in time range) fentaNYL (SUBLIMAZE) injection 100 mcg (has no administration in time range) LORazepam (ATIVAN) injection 2 mg (has no administration in time range) etomidate (AMIDATE) injection (30 mg Intravenous Given 1/4/22 1734) EPINEPHrine 1 mg/10mL syringe (1 mg Intravenous Given 1/4/22 1808) sodium bicarbonate 8.4 % injection (50 mEq Intravenous Given 1/4/22 1751) rocuronium (ZEMURON) injection (100 mg Intravenous Given 1/4/22 1734) anti-inhibitor coagulant complex (FEIBA) injection 5,044 Units (5,044 Units Intravenous Given 1/4/22 1829)   Subjective    HISTORY OF PRESENT ILLNESS: HPI  62yo male working in a shop when he began acutely complaining of shortness of breath. EMS reports that they witnessed a respiratory arrest with PEA. CPR was initiated ROSC achieved after 8-12 minutes. No shocks given. No meds were given as no access was established prior to ROSC. Left tibial IO in place on arrival.   Review of Systems Unable to perform ROS: patient unresponsive    PAST MEDICAL HISTORY No Known Allergies  Past Medical History: Diagnosis Date ? Abdominal aortic aneurysm (AAA)   ? Ascending aortic aneurysm    ? At risk for falls   ? Bacteremia due to methicillin susceptible Staphylococcus aureus   ? BPH (benign prostatic hyperplasia)   ? Calcific aortic stenosis of bicuspid valve 03/08/2019 ? Congestive heart failure (CHF)  08/21/2009 ? CVA (cerebral vascular accident)    ? Diastolic heart failure    ? Heart disease   ? HTN (hypertension)   ? Hypercholesterolemia   ? Left ventricular hypertrophy   ? Obesity    Past Surgical History Past Surgical History: Procedure Laterality Date ? HX AORTIC VALVE REPLACEMENT   10/02/2019   Willekes. AV Replacement 25 Magna, ascending aorta replacement ? HX AORTIC VALVULOPLASTY       Hx of aortic stenosis / bicuspid aortic valve with valuloplasty as child ? HX ASCENDING AORTA     ? HX KNEE ARTHROSCOPY Left   ? HX TONSILLECTOMY      Social History:  reports that he has never smoked. He has never used smokeless tobacco.  reports previous alcohol use of about 4.0 - 6.0 standard drinks of alcohol per week.  reports no history of drug use.   Family History Family History Problem Relation Age of Onset ? Breast Cancer Mother   ? Cancer Father 55       brain cancer ? Anesth Problems Neg Hx    Objective   ED Triage Vitals Temperature Pulse Respirations BP SpO2 01/04/22 1922 01/04/22 1726 01/04/22 1726 01/04/22 1726 01/04/22 1726 36.7 °C 90 12 (!) 115/101 98 %   Temp src Heart Rate source Patient Position BP Location FIO2 (%) -- -- -- 01/04/22 1747 01/04/22 1906       Right arm 100 %   Physical Exam Constitutional:      Appearance: He is obese.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Comments: Pupils 3 mm, equal, non-reactive  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Comments: Bagged via I-gel LMA device. Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Comments: GCS 3. No response to noxious stimuli. No gag or cough reflexes.     WORK UP: Labs: Labs Reviewed COVID-19, INFLUENZA A/B, RSV PCR - Abnormal; Notable for the following components:     Result Value Ref Range Status   COVID-19 PCR Detected (*) Not Detected Final   Comment: COVID-19 (SARS-CoV-2) test is positive. Clinical correlation with patient history and other diagnostic information is necessary to determine infection status.