Case Studies

Read the vignettes below and think about appropriateness for therapy and potential evaluation/treatment focus.

Case Study #1

Pt is a 36 y/o male who presented on 11/16 as a Code Trauma activation after sustaining GSW's to posterior head and R shoulder. Per EMS report patient was seated in the car when multiple gunshots were fired. Initially patient was responsive to painful stimuli with L-sided seizure activity, R side flaccid. Subsequently, Pt became unresponsive and developed decorticate posturing in LUE. He was intubated in the field. Sutures placed for head exit/entrance wounds, EVD placed, mannitol for swelling. Extubated 11/20. CT head showed PO lobe trajectory to RF lobe passing through L lateral ventricle, intracranial bullet, and skull fragments with SAH and IVH.

Summary of Injury:

  • R posterior trapezius bullet wound with fragment next to clavicle with hematoma

  • Bullet tracking L posterior to R anterior. Multiple shrapnel and skull fragments along the bullet trajectory, main projectile remains intracranial. Extensive hemorrhage along the bullet track.

 

  • Opens eyes to stimulation, but does not regard or track. Left gaze preference. LUE and LLE intermittently following commands to squeeze fingers and wiggle toes. No purposeful movements with RUE or RLE. 

  • +cough/L corneal, weak R corneal/ no gag. Intermittently following commands- more consistent this evening- smiling, weak L hand grasp and wiggling L toes. Withdrawing RUE, triple flex RLE. +right facial droop. No speech.

  • EVD open at 5 with serosanguinous output

  • ICP <20

  • Daily TCDs: uptrending on 11/21, but stable/down trending on 11/22

  • SBP goal <200, Nicardipine PRN

  • Lines: EVD, a-line

Case Study #2

Pt is a 77 y/o man with PMH significant for Afib (on apixaban) and unspecified prior stroke (2015, residual WFD) who presented to BWH as OSH transfer on 11/5 after being found down in the evening (LSW noon) and found to have a left frontoparietal IPH with IVH, worsening hydrocephalus, and MLS s/p 11/10 EVD and intubation for worsening mental status/resp status. Course c/b ongoing fevers, HAP, UTI, seizure now on LEV 1000mg BID, and labile BP reads. EVD d/c 11/19.

 

  • Vent Mode:   PS/CPAP    FiO2: 30 %

  • SBP goal <160

  • SpO2 goal >88%

  • occasional spontaneous movement in LUE/LLE. Opens eye for short periods to stimulation and pain; not fixating, blink to threat on L but not on R. No command following

  • Amantadine 200 BID

Case Study #3

Pt is a 67 y/o male with PMH significant for COVID 4/2021 c/b PE and ESRD (prev on HD), A-fib and FVL (on warfarin), and recent hospitalization for staph epi bacteremia who presented to BWH on 11/14/21 as OSH transfer s/p intubation for acute right sided weakness and aphasia s/p tPA (11/14) found to have L M2 occlusion (not IAT candidate). C/b likely endocarditis 2/2 MV abscess vs. caseous annular calcification (on meropenem); aspiration PNA. Exam clouded by sedation but remains poor, surveillance CT shows new infarcts ? In the right thalamus and right occipital lobe. Seems to be moving LUE more spontaneously this AM though.

 

  • AC/VC with PEEP 12

  • Desaturates significantly with repositioning/bed mobility

  • Requires Fentanyl bolus for repositioning

  • SBP is above goal; SBP 140s-160s.

  • Opens eyes to stimuli and localizing with LUE. No movement in RUE, withdraws LLE and triple flex RLE. No commands.