Case Study

Lindsay Trantum ACNP-BCVUMC Neurological ICU

Case Study• Mr. Cam is a 73 y/o male with hx of HTN,

COPD, smoking and hyperlipidemia admitted for acute right MCA CVA. His hospital course has been complicated by cerebral edema requiring decompressive craniectomy, UTI, non-convulsive status epilepticus requiring ativan prn and persistent electrolyte abnormalities.

Case Study• On hospital day 4, the bedside RN comes to

you and says that Mr. Cam is complaining that spiders are crawling all over him and he’s screaming that we are all trying to kill him.

What is the most likely diagnosis?

A. Paranoid schizophreniaB. ICU deliriumC. Altered mental statusD. Sepsis

What tests would you order?

A. UA and cultureB. Comprehensive metabolic panelC. AmmoniaD. Non-contrasted head CRE. All of the above

Case Study

• 2 hours later, Mr. Cam’s nurse comes to you and says that he is biting and spitting at the staff and becoming increasingly more agitated

What is the most appropriate pharmacologic intervention?

a. Lorazepam 2mg IV q2h prn

b. Seroquel 25mg BID increase by 25mg q12h until desired effect

c. Haldol 2.5mg q2h prnd. Both a and ce. Both b and c

Case Study• On hospital day 8, Mr. Cam becomes

hypoxemic and lethargic. You decide he needs to be intubated.

Which sedative would you choose?

a. dexmedetomidineb. Propofolc. Fentanyld. Versede. Either a, b or c

What interventions will assist you in decreasing Mr. Cam’s delirium?

a. SBT and assess for extubation daily

b. Keeping him sedated with fentanyl and versed until ready to extubate

c. Early mobilityd. Use of eye glasses and

hearing aidese. Maintaining a day/night

cyclef. A, C, D, Eg. A, B, D, E

Identify Mr. Cam’s delirium risk factors

a. UTIb.Intubation/

Respiratory failurec. Stroked.Electrolyte

Abnormalitiese.Lorazepam

administrationf. All of the above

Case Study• On hospital day 11, Mr. Cam is extubated.

That evening, he starts picking at his IV sites and pulling on his foley.

What is your next course of action?

a. Versed 2mg IV prnb. Re-intubate for his

safetyc. Continue Seroquel and

prn haldold. Add dexmedetomidinee. Both c and df. None of the above

Case Study

• On hospital day 16, Mr. Cam’s ICU delirium clears. He is transferred to the floor and eventually to in-patient rehab. Unfortunately, he still suffers from mild long-term cognitive impairment.