Age: 15.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Magnetic resonance imaging head abnormal, Mechanical ventilation, Medical induction of coma, Mydriasis, Myocardial stunning
Clinical narrative: In brief, patient is a previously healthy 15 year old who had acute headache and collapse at home, concern for posturing versus seizure, and ultimately found to have cerebral and intraventricular hemorrhage with mass effect secondary to ruptured aneurysm. S/p coiling of aneurysm, bilateral EVD placement and R decompressive craniectomy. She has acute respiratory failure, strep viridans bacteremia, and concurrent COVID-19 infection.  Presented 12/2/21 with aneurysm and incidentally found to be COVID positive.   NEURO: On arrival, she was somewhat responsive and by the time she arrived at ED she was posturing versus seizing. Head CT revealed hemorrhage 3x3x3 hemorrhagic focus anterior and inferior to the right basal ganglion with mass effect, also with intraventricular blood in lateral and third ventricles with acute subarachnoid hemorrhage in suprasellar cistern and bilateral sylvian fissures. At that time, reportedly pupils equal, 3-4, minimally reactive. At ED, received Mannitol bolus, and 4mg Ativan administered. Flight for Life activated and upon arrival to CW was admitted to the PICU with plan for emergent EVD placement. Neurosurgery placed EVD at bedside. Repeat head CT and CTA performed and demonstrated bilobed aneurysm arising from right ICA terminus with enlarging intraparenchymal hematoma along superior aspect mostly likely representing a ruptured aneurysm, increased intraventricular hemorrhage, similar subarachnoid hemorrhage, increased mass effect, effacement of basal cisterns, worsened midline shift. Optimized neuroprotection management with sedation, neuromuscular blockade, ventilator management, and hypertonic saline. R pupil became dilated and nonreactive and patient demonstrated persistently elevated ICPs >50. She underwent emergent IR coiling and R decompressive craniectomy with second right-sided EVD placement. Patient continued to demonstrate ICPs in 20s. Worked with Neurosurgery to optimize sedation. Repeat head CT demonstrated increased hypoattenuation in right frontal and parietal lobes, left parietal lobe, and splenium of corpus callosum. Loss of gray-white differentiation concerning for ischemic change. Increased right to left midline shift. TCDs demonstrated moderate spasm of the L MCA. EEG without seizure. Started Pentobarbital coma. On 12/9, an occurred episode while in transport to MRI and patient was noted to be obtunded. ICP 11 during episode, EVDs patent. She was not connected to LTM during episode, as she was in transport. She was started on epi drip and became more responsive, moving spontaneously and withdrawing to pain. On 12/10, her neurostorming medication regimen was optimized and no further changes were made.    Given poor neurologic prognosis, patient was given adequate sedation for pain management during terminal extubation on 12/18.  CV: Had periods of hypotension intraoperatively requiring initiation of Epinephrine and Norepinephrine infusions to maintain goal MAP > 80, SBP > 120. Returned to PICU with femoral CVL, arterial line, sedated with Fentanyl and Dexmedetomidine infusions, and on Vecuronium infusions, Nimodipine. On 12/4 echocardiogram report noted significant for left ventricular mid-inferoseptal hypokinesis and moderately diminished left ventricular systolic function, with an LVEF 41%. She required titration of pressors to maintain goal pressures. Added stress dose Hydrocortisone. Repeat echocardiogram demonstrated significant improvement in LV systolic function, consistent with the hypothesis that myocardium was neurologically stunned. 12/6-12/8 Patient weaned from sedation and pressors. On 12/9 she experienced a hypotensive episode while in transport to MRI.  HR dropped to 40s-50s. 105 mcg Epi dwindle given, then started on Epi drip, given 500 mL NS push pull. HR and BP normalized. On 12/10, patient was weaned from pressors and stress dose steroids. She remained hemodynamically appropriate leading to terminal extubation on 12/18.   RESP: Intubated in the OR. Notably, course complicated by significant pulmonary edema with poor compliance. On 12/10, her ventilator settings were weaned to CPAP/PS. She remained hemodynamically appropriate with CPAP/PS until terminal extubation on 12/18.   FEN/GI: On 12/10 patient was started on enteral feeds which were discontinued after terminal extubation on 12/18.   ID: At ED, she was incidentally found to be COVID positive. Blood cultures were drawn at that time positive for strep viridans. She started on empiric Cefepime and Vancomycin due to concern for septic shock given pressor requirements. Initiated thermoregulation. Patient continued to be intermittently febrile and remained on Ceftriaxone per family's wishes until 12/19.   RENAL: Initially had significantly increased urine output. Labs concerning for DI, although could also be secondary to 3% boluses. Initiated DI protocol. This later resolved and she continued to have urine output appropriate for age leading to her terminal extubation on 12/18.   OTHER: On 12/5 ,discussion took place between provider and mother and placed partial code status, including no bolus cardiac resuscitative medications, no defibrillation, no chest compressions. Care Conference took place on 12/10, during which mother voiced she would like to get MRI for further neuroprognostication before changing goals of care. Care conference on 12/14 to discuss MRI results with family. Neurology explained likely deficits patient will experience as a result of her brain injury including weakness of both sides of her body, inability to walk, inability to effectively eat PO, personality changes, cognitive dysfunction. Mother voices "Patient would not want to live like this," but requests time to discuss these options with family before making any decisions. Another discussion between providers and family on 12/15 during which family voiced they would not want patient to be reintubated once extubated, would not want her to receive blood products, and would like to continue with enteral feeding. Tentative plans for extubation on 12/17 or 12/18 once family from out of state has come to say their goodbyes. Family later decided to move forward with terminal extubation on 12/18. She was extubated 12/18 to room air and passed away on 12/19/2021 @ 20:37 PM with mother, brother and step father at the bedside.