CASE WRITE UP

FACULTY OF MEDICINE

CRITICAL CARE DEPARTMENT

NAME DINESH KUMAR KARUNAKARAN

STUDENT ID BMS19096230

GROUP 2

POSTING CRITICAL CARE

INDEX

1. Patient Information
2. Background
i. Chief complaint
ii. History
iii. ED
3. Physical Examination (ICU)
4. Investigation
5. Cause of referral to ICU
6. Course of case from admission
a. Provisional diagnosis
b. Monitors used and rationale
c. Management
i. Essential care
ii. Specific care
1. Airway management
2. Ventilatory management
3. Course of Vital signs
4. Lab report & ABG
5. Any critical event
6. Outcome of patient
7. Discussion
i. Status epilepticus
ii. HAP (Hospital Acquired Pneumonia)
8. ICU admission criteria
9. Indication for ICU admission
10. Reference
1) Patient Information

Name: ZAINAH BINTI HARUN

Age: 65-year-old

DOB: 23/12/1957

Gender: Female

Ethnic: Malay

Marital status: Single

Hospital admission: 03/02/2023

Date of admission into ICU: 06/02/2023

2) Background

i) Chief complaint - A 65 year old epileptic patient became less responsive

and brought to the ED.

​ ii) History
​
Patient developed a seizure on 25/1/2023 and fell, sustained bruises and
swelling over her left forehead and right shoulder. Later she did not seek any
medical attention. Since then, daily she had 2-3 episodes of seizures, aborted
spontaneously.
​ The seizures became more frequent, she had 6 episodes on 2/2/23 and 10
episodes on 3/2/23 and the patient became less responsive and also she
developed fever and cough on the same day. She was brought to the
Emergency Department, HKL on 3/2/2023.
​
​ Underlying Condition:
​
​ - Epilepsy diagnosed at 12 years old she is on Epilim 200 mg OD- OTC
medication, defaulted to follow up under Hospital Selayang for 8 years.
​ - slow learner and ADL independent.
​ - No significant family history.

iii) ED

​ On arrival to ED,
​
● GCS E2V2M5, pupils 2/2 reactive, power 3/5 right UL/LL, 5/5 left UL/LL
● Vital signs
 ○ Temperature - 37.3°C.
○ Pulse rate - 78 beats per minute,
○ Respiratory rate - 14 breaths per minute,
○ spO2 - 100% under Non-rebreathing bag mask
○ Blood pressure (Non-Invasive) - 98/70 mmHg
○ Blood glucose (dxt) - 6 mmol
● The patient's lungs are clear.
● Curdy white discharge from vagina and foul smelling urine.
● She was given
○ IV phenytoin 1g,
○ IV cefuroxime 1.5g stat,
○ IV Epilim 800mg stat (TDM Epilim subtherapeutic)
● Later she developed recurrent episodes of seizures in the ED, uprolling
eyeball, twitching of left face, tonic-clonic left UL were seen.
● The patient's GCS didn't return to baseline; so she was intubated for airway
protection and her GCS pre-intubation was E4V2M4 (blank stare).
​
​
3) Physical Examination (ICU)

General examination: The patient was intubated and sedated with

midamorphine 5ml/h

​
​ Vital signs:
​ Temperature - 36.7°C.
​ Pulse rate - 104 beats per minute,
​ Respiratory rate - 12 breaths per minute,
​ spO2 - 99% (ventilator)
​ Blood pressure (Non-Invasive) - 164/74 mmHg
​
​ Neuro examination: GCS E1VTM3, good cough gag
​
​ Cardiovascular examination: supported noradrenaline 20 mcg/min, MAP 94
and lact 1.2
​ ,
​ Respiratory examination: Lung clear. Vesicular breathing with equal air entry
on both sides of the chest.
​
​ Abdominal examination: Soft
​
​ Extremities: Coolish peripheries and pulse volume was fair
​
4) Investigation

I. Before admission (in ED)

Complete blood count, Coagulation profile, Blood urea and serum electrolyte
(BUSE), EEG, CT scan and arterial blood gas (ABG).

II. On admission (in ICU)

Complete blood count, renal profile, coagulation profile, liver function tests,
cardiac enzymes test, group, screen and hold (GSH), group checking and
matching (GXM), blood urea and serum electrolyte (BUSE), venous/arterial
blood gas, chest X-ray.

5) Cause of referral to ICU

Intensive therapy and monitor. The patient CT shows Left frontal and parietal
vertex scalp hematoma, no ICB/skull bone fracture. Old Lentiform nucleus
infarct. Small vessel disease.

- Intervention to manage the status epilepticus and aspiration

pneumonia

6) Course of case from admission

​
​ a) Provisional diagnosis
1. status epilepticus with u/L epilepsy secondary to non-compliance
​ 2. aspiration pneumonia
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 ​ b) Monitors used and rationale

Purposes Monitor Rationale

Used

Oxygenation Oxygen To ensure adequate inspired oxygen concentration

analyzer in the patient.

Pulse To ensure adequate oxygen concentration in the

oximeter blood.

Ventilation Capnography To continuously measure and analyse end-tidal

carbon dioxide when the patient was intubated,
and determine the adequacy of ventilation.

Respiratory To monitor adequate ventilation of the patient.

rate

Circulation Electrocardio To monitor cardiac electrical activity of the patient.

gram

Invasive To monitor arterial blood pressure of the patient.

Blood
Pressure

Heart rate & To monitor the circulatory function of the patient.

Pulse rate

Temperature Thermometer To detect thermal disturbances and maintain

(Axillary) appropriate body temperature.
c) Management

I. Essential care

Essential care Management

Feeding / Fluid Feeding :

● Patient was on enteral feeding via nasogastric tube.

Ensure 100cc/3hr

Management :

● Arterial line was set up on the right radial artery.

● IV fluid was dripped with a pressure bag (white pump
bag)
● IV Epilim 600 mg
● IV phenytoin 100 mg

Analgesia ● Patient was given Morphine

Sedation ● Sedation was sedated with Midamorphine.

Thromboprophyla ● Patient was given SC Enoxaparin (Clexane) 60 mg 12

xis hourly for 5 days

Head elevation ● Patient’s head was elevated at 35o

Stress ulcer Patient was given IV Pantoprazole 40mg (Proton Pump

prophylaxis Inhibitor)

Glucose control Patient was given IV MgSO4 10 mmol.

II. Specific care

(a) Airway management

Endotracheal tube intubation.

Type: PVC and cuffed.

ETT Size - 7.5

ETT Marking - 20

(b) Ventilatory management

CPAP (continuous positive airway pressure)

Ventilator mode CPAP

FiO2 30

RR(spontaneous) 14

VT(Expired) 405

PEEP 8

Pressure support 10

(c) Course of Vital signs

Vitals
7/02/2023 at 08/02/2023 at 0800H
0800H

Temperature (°C) 37.5 (skin) 37.2 (Axillary)

Heart rate (beat/min) 117 109

Arterial Blood pressure (mmHg) 102/60 150/78

SpO2 (%) 100 99

Respiratory rate (breath/min) 15 26

d) Lab reports & ABG

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​ e) Any critical event
Uneventful.
​
​ f) Outcome of patient
Slight improvement of vital signs. The patient is tolerating CPAP overnight,
remains afebrile and under ventilation with a GCS score that is still very poor
at 6/15.
7) Discussion

i) Status epilepticus

Status epilepticus (SE) is a medical emergency associated with significant

morbidity and mortality. SE is defined as a continuous seizure lasting more
than 30 min, or two or more seizures without full recovery of consciousness
between any of them. Based on recent understanding of the pathophysiology,
it is now considered that any seizure that lasts more than 5 min probably
needs to be treated as SE. GABAergic mechanisms play a crucial role in
terminating seizures.

When the seizure persists, GABA-mediated mechanisms become ineffective

and several other putative mechanisms of seizure suppression have been
recognized. Early treatment of SE with benzodiazepines, followed if
necessary by fosphenytoin administration, is the most widely followed
strategy. About a third of patients with SE may have persistent seizures
refractory to the first-line medications. They require aggressive management
with second-line medications such as barbiturates, propofol, or other agents.

In developing countries where facilities for assisted ventilation are not readily
available, it may be helpful to use non sedating antiepileptic drugs (such as
sodium valproate, levetiracetam, or topiramate) at this stage. It is important to
recognize SE and institute treatment as early as possible in order to avoid a
refractory state. It is equally important to attend to the general condition of the
patient and to ensure that the patient is hemodynamically stable.
Table above shows: Systemic and cerebral pathophysiological changes
associated with convulsive status epilepticus
ii) Hospital-acquired pneumonia (HAP)

Hospital-acquired (or nosocomial) pneumonia (HAP) and ventilator-associated

pneumonia (VAP) are important causes of morbidity and mortality despite improved
prevention, antimicrobial therapy, and supportive care.

● Hospital-acquired (or nosocomial) pneumonia (HAP) is pneumonia that

occurs 48 hours or more after admission and did not appear to be incubating
at the time of admission.
● Ventilator-associated pneumonia (VAP) is a type of HAP that develops
more than 48 hours after endotracheal intubation.

Inhalation, aspiration, and hematogenous spread are the 3 main mechanisms by

which bacteria reach the lungs. Primary inhalation pneumonia develops when these
organisms bypass normal respiratory defence mechanisms or when the patient
inhales aerobic gram-negative organisms that colonise the upper respiratory tract or
respiratory support equipment.

Aspiration pneumonia results from aspiration of colonised upper respiratory tract

secretions. In healthy individuals, roughly 45% of the population is estimated to
aspirate during sleep, with critically ill patients likely aspirating more frequently.

The stomach appears to be an important reservoir of gram-negative bacilli that can

ascend and colonise the respiratory tract. A prospective observational study found
that patients who used acid-suppressive medications were more likely to develop
hospital­acquired pneumonia (HAP) than were patients who did not (5% vs 2%). The
risk for pneumonia was significantly increased with proton pump inhibitors, but not
with histamine 2-blocking agents.

Common bacteria involved in hospital-acquired pneumonia (HAP) include the

following :

● Pseudomonas aeruginosa
● Staphylococcus aureus, including methicillin-susceptible S aureus
(MSSA) and methicillin-resistant S aureus (MRSA)
● Klebsiella pneumoniae
● Escherichia coli
● Non-Enterobacteriaceae bacteria such as S.marcescens,
Stenotrophomonas maltophilia, and Acinetobacter species are less
common causes. Acinetobacter species commonly colonize respiratory
tract secretions in patients in the ICU. HAP caused by Acinetobacter
species or B cepacia may be associated with outbreaks. Streptococcus
pneumoniae and Haemophilus influenzae are recovered only in
early-onset HAP.
8. ICU admission criteria

Criteria In this patient

Prioritisation according to the patient’s severity of ✔

illness

Specific patient needs such as life-supportive ✔

therapies

Diagnosis ✔

Prognosis ✔

Potential benefit from interventions ✔

Objective parameters at the time of referral ✔

Available clinical expertise & Bed availability ✔

9. Indication of ICU admission

Indication In this patient

Intensive monitoring
✔

Intensive Therapy
✔

Organ preservation in brain dead patient for organ

donation
10. References

I. Colledge, N.R., Walker,B.R. and Ralston, S.H., (2010). Davidson’s Principles

and Practices of Medicine (21st Edition). Churchill Livingstone Elsevier.
II. Kumar, P. and Clark, M.L., 2020. Kumar and Clark's Clinical Medicine (10th
Edition). Elsevier Health Sciences.
III. ICU Management Protocols by Malaysian Ministry of Health & Malaysian
Society of Intensive Care.
IV. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824929/