NYU Medical Grand Rounds Clinical Vignette

Sarah MacArthur, MDTuesday January 22nd, 2013

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Ms. H is an 82 year old woman who presented with neck pain for 4 hours.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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.

History of Present Illness

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.

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DEPARTMENT OF VETERANS

AFFAIRS

• Acute type II Dens fracture with displaced fragments

Working or Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was admitted to Neurology for initial treatment with cervical collar and with plans to discuss her case at spine conference.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• In the MICU the patient had an extensive work-up.

• 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• On Hospital Day 9, extubated and stable, the patient was transferred to the medicine floors with plans for discharge to Hospice.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• PEA arrest from hypoxic respiratory failure.

Final Diagnosis

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DEPARTMENT OF VETERANS

AFFAIRS