Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if
you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
My Mom is in the ICU and is Fluid Overloaded. Are They Watching the Fluid Balance Closely?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Stephanie as part of my 1:1 consulting and advocacy service! Stephanie’s mother is a
post cardiac arrest patient in the ICU and is asking why the ICU team tells that a Glasgow coma scale of 3 is a clear indication of a brain injury?
My Mother Is Critically Ill in the ICU. Why Does the ICU Team Thinks That a Glasgow Coma Scale of 3 is a Clear Indication of A Brain Injury?
PART 1
PART 2
PART 3
PART 4
PART 5
PART 6
PART 7
PART 8
PART 9
PART 10
PART 11
PART 12
PART 13
PART 14
PART 15
PART 16
PART 17
PART 18
PART 19
PART 20
PART 21
PART 22
PART 23
PART 24
PART 25
Stephanie: Hey, Patrik?
Patrik: Yes. Hi Stephanie.
Stephanie: There you are. I’m giving you to Dr. Morgan. Just you and him can talk if you want to.
Patrik: Thank you so much.
Stephanie: Do you need me to be on? I guess I’ll be on because I do wanna hear, okay?
Patrik: It would be great if you were, but I don’t know whether that’s possible logistically.
Stephanie: Yeah, it is. Five seconds.
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Dr. Morgan: Hey, Patrik. Sorry we got a little bit lost for a minute.
Patrik: That’s okay, that’s okay. How is your day going? You busy?
Dr. Morgan: What was that?
Patrik: How is your day going? Are you very busy?
Dr. Morgan: Yeah. Unfortunately, always busy here in the ICU.
Patrik: I would imagine.
Dr. Morgan: Overall… change is going on with Carmen. The big thing is we’re scheduling her for Thursday for the tracheostomy and the PEG placement. We don’t know exactly when that day will be-
Stephanie: Time.
Dr. Morgan: Oh, sorry, the time. We know the day, but not the time. Things at least for now is… she keeps having evidence of infection. She now has a gastric pneumonia, her mouth essentially, that fall into the lungs. So, we have her on antibiotics again. So, she’ll undergo another course for the pneumonia
and lung infection. The good news is that her seizures are very well controlled… thanks to that. Most of it is probably, just stabilisation and maintaining her until Thursday, till she gets those procedures done.
Patrik: And when you’re saying the seizures are well controlled, I understand she hasn’t had any seizures for quite some time now, but at the same- for some reason, she’s not waking up either. Her GCS would be around a 5?
Dr. Morgan: Currently her GCS from me, today, was a 3. So, it’s not great and that correlates well with the neuroprognostication and everything we’ve done. Again, brain injury due to the hypoxic arrest. If the family wants to go ahead and give her every chance she can get and hope for
some recovery, I think the best way to go about that is by going with this tracheostomy and the PEG.
Patrik: That would buy her time, that would buy her time.
Stephanie: That’s good to hear.
Dr. Morgan: Right, right, right. One of the things that her family will have to realise though is there may not be potential recovery. We don’t know yet. We want you guys to understand, going forward, that there may be a possibility for that in the future.
Patrik: Yes, absolutely. I mean, you said last Glasgow Coma Scale of 3, I mean you mentioned that, you know, it’s potentially a sign of the brain
injury and there is no sign from you that she’s too sedated at the moment to control the seizures, you think the Glasgow Coma Scale of 3 is a result of the brain injury.
Stephanie: He says do you think that the Glasgow Coma Scale of 3 is clearly an indication of the brain injury, not because she’s on any seizure medications or sedatives.
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Dr. Morgan: So, the Glasgow Coma Scale isn’t indicative of anything. It’s more of an assessment. Overall the Glasgow Coma Scale is not really a tool that’s used for neuroprognostication it’s more for trauma. Usually it’s something we don’t follow on a consistent basis, determine a GCS. The things that we have beyond that are some of the MRI, the EEG, in a focused neurologic examination that we do on daily basis because those are more indicative of
the potential for hypoxic brain injury. In all of those tests, those have all been very suggestive in, and they’re showing definitive findings that there is significant neurological injury. If you take someone with a massive head bleed, and they could have a GCS of 3, then you could
also take someone who has drank too much one night and pass out-
Patrik: Absolutely, absolutely.
Dr. Morgan: Their call would be 3. But obviously they’re certain conditions. The GCS is more for like, a rapid assessment and trauma from an outpatient case. How do we assess-
all right well her GCS is 8, 3 or 14-
Stephanie: That varies and quite low.
Dr. Morgan: Right, exactly.
Patrik: No, I understand. I understand that. Okay so once she has the trach, I understand she’s still on Phenobarbital, would you be changing the level of sedation and anti-seizure medication once she has the PEG or… just carry on as usual.
Dr. Morgan: So, she’s very well controlled on the current medication regimen she’s on now. So, the brain is showing clinical evidence of seizures, then we wouldn’t adjust it because she’s very well controlled and we think these doses are doing their job. So, there’s really nothing to change, and having the
PEG and having the trach won’t change that.
Patrik: Yeah. No, no, I understand, I understand. And with the PEG, I mean… now is she taking any breaths herself or is she fully ventilated? Is she doing any work herself with the ventilation? Or…
Dr. Morgan: She still has her ability to breathe on her own and this isn’t because-… We are giving her breathing trials and she does pass most days, but there’s some days that she fails, which is fine. So, she can breathe on her own when we temporarily take her off the ventilator.
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Patrik: Okay. So, then it could change that, once she has the trach, she can go on a collar, at least for a little while here and there.
Dr. Morgan: With any person who has a tracheostomy, it’s always a possibility to wean them off the ventilator to a trach collar. And they would be on that, essentially, reversal of the tracheostomy and so that’s always something to be considered. Although, I just will caution at least, that I think the likelihood of Carmen being able to do that may be… not very good. But again, this is the plan of care that you
guys want to do that so, it is a possibility.
Patrik: No, I understand. We know she may not improve, we’re just trying to find out… what are the next steps? What’s the likelihood of her recovery? And that sort of our questions. Regarding that, does she have a pulse? Can she pulse? Probably not with the GCS of 3 now.
Dr. Morgan: Yeah, she does have a lot of reflexes. She has this cough, she has a gag reflex, she has positive pupil reflex, she has a corneal reflex. So, a lot of the brain stem reflexes are still intact, but again, the brain system is a very basic form of human interaction. But it doesn’t mean she is okay, and still indicative of significant injury, but I mean, it’s still… she’s not what we would say ‘brain dead’. If she had none of those
reflexes, she would be brain dead.
Patrik: And in terms of other organs failing… it sounds to me now, like it’s the brain and the lungs that are affected. I mean, her heart, even though she had a cardiac arrest, her heart, she’s not on any vasopressors, you know…
Dr. Morgan: Right. We were a little bit concerned a couple of days ago when she had that new x-ray and CT scan, that she would, because her blood pressure did drop a little bit, but it responded very well to fluids. Her liver does have evidence of slight inflammation, but that’s due to the fact, she’s on medication to help control the seizures. It’s very mild and discerning. Her GI tract is working well, she’s having bowel movements, she’s getting nourishment through her tube feed. Her kidney function is good, she was not making a lot of urine before, that’s picked up now. What else do we got?
Stephanie: How about the problem in her lungs?
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Dr. Morgan: I think yesterday there’s a little bit of confusion. She built up fluid in her lungs and things and so we can’t really address that too right now because we want to be very careful with her blood pressure and to get the fluid out of the lung, right. And so, we don’t want to, in the acute infection stage, if the fluid in the lungs isn’t bothering her too much, and by that I mean not increasing her oxygen requirements, then we want to
try to wean her off the ventilator because we don’t want to taint her blood pressure. We do acknowledge the fact that she should get some sort of, what we call ‘diuresis’ at some telling. But for now, she’s out of the acute stage.
Patrik: How much oxygen is she on by the way, when you mentioned that? Is she on more than 40% of oxygen or… what’s her oxygen level now?
Dr. Morgan: 40%? It’s 35%. Taking away that-
Patrik: 35%. Got it. Right.
Dr. Morgan: She’s on less oxygen, which is a good finding, given that she was having an active lung infection.
Patrik: Yes, yes. No, absolutely, absolutely. Okay. So that’s positive, I mean, with the cardiac arrest, is her heart in a reasonably stable condition? Has the heart recovered from that? Or is that an ongoing concern as well? I mean, she’s off the vasopressors, I understand that. Are there any ongoi-, She’s either regular rhythm, arrhythmias rhythm, or is she in the irregular rhythm?
Dr. Morgan: Sinus rhythm. And for all intents and purposes, the stent is opened and perfusing the heart. The only question from this stand point is, she’s supposed to be on what we call ‘dual anti-platelet therapy’ but she was showing evidence of anaemia and a potential bleed so we had to hold the anti-platelet medications and my concern… because of the bleed we don’t want to restart it, but she is at rick to have that stent blocked off but right
now it’s an accepted risk because we don’t want her to bleed out. We also want her to have the tracheostomy done on Thursday.
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Patrik: Absolutely. And then you would restart that therapy? Or…
Dr. Morgan: Immediately after that, we’ll have to start it as soon as possible.
Patrik: Yeah, yeah. Because you don’t want the stent to block off, of course.
Dr. Morgan: No, definitely not.
Stephanie: Do you think that you would sit her up at any point? Do you think we would sit her up at any point after she gets the tracheostomy?
Dr. Morgan: How do you mean?
Stephanie: So, she won’t be just lay down flat. Like every now and then, a chair or something.
Dr. Morgan: It would be difficult because she’s not going to be cooperating much but there may be some physical therapy programmes that can-do early mobilisation and just a range of motion exercises just to keep everything… yeah.
Stephanie: What do you think of that Patrik?
Patrik: I think that would be fantastic. I mean, I understand there could be a fine line by doing physical therapy and potentially triggering a seizure, that could be a fine line. But, at the same time, she’s basically been immobile for 2 weeks. From my perspective and experience, I mean, sitting somebody up
or mobilising them with a PEG is so much easier, compared to a breathing tube. It’s a much safer airway.
Stephanie: Yeah.
Patrik: But… somebody must find out can she recover, you know, and that would be one way-. One way to find out, from my perspective, would be to start stimulating her, if it’s not triggering any seizures.
Stephanie: Right. Got you. That’s the next step. It’s a possibility.
Patrik: It sounds like it’s really-, the brain is a concern, obviously the lungs are a concern because of the ventilation still. And everything else seems to work okay. After the PEG has been done, the next step and assessments can be done.
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Dr. Morgan: What was that?
Patrik: I said after the trach has been done, maybe the next steps can be taken. As I said like, maybe mobilisation, maybe physical therapy, and hopefully she won’t have any seizures, you know.
Dr. Morgan: Right. We hope.
Patrik: Yeah, yeah. And with the seizures, she’s on Keppra, Phenytoin or Dilantin, and Phenobarbital, to keep that control.
Dr. Morgan: Correct. She’s on Vimpat, Valproic acid, and Phenobarbital.
Patrik: Right.
Stephanie: Also Vimpat?
Dr. Morgan: Is there also… Valproic acid or Depakote? Or Lacosamide, or sort of Vimpat.
Stephanie: The Lacosamide is the same as-
Dr. Morgan: Vimpat.
Stephanie: The Vimpat. It’s like the same as-
Dr. Morgan: Valproic acid is the same as Depakote.
Stephanie: Yes, anti-seizure.
Dr. Morgan: All right, do you have any other questions for me, Patrik?
Patrik: No, thank you so much for your help. I really appreciate your time. Thank you so much. All the best. Thank you, thank you, bye-bye.
Stephanie: Okay, thank you so much. Thank you. Oh boy. I knew you would understand it better than I did, so.
Patrik: I was about to ask, could you hear what we were talking about?
Stephanie: Yes, I did everything.
Patrik: Right, okay. I mean you could obviously hear him clearly because you’re standing next to him, but you could also hear me.
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Stephanie: Yeah. Every word.
Patrik: Right. You’ve done a crash course in ICU in the last few days.
Stephanie: Yeah. Yes, I have. Yes, I have.
Patrik: Absolutely, absolutely. So, there are no surprises really, I think there are no surprises really in terms of what’s happened and what’s being happening. I mean, we’ve been pretty good asking questions in the last few days. The only thing that I didn’t know, was that they stopped the blood thinners, which they would have done but, you know, they need to restart them after the trach has been done because the stents. She will be on those
blood thinners for the rest of her life, right?
Stephanie: That’s true.
Patrik: Because if the stents blocked off, she could have another cardiac arrest.
Stephanie: Exactly.
Patrik: Right. So-
Stephanie: But they could put another stent in there.
Patrik: Yeah, well, yeah, yeah. What he is doing, what I didn’t like 100%, he was downplaying, sort of, the GCS a little bit, you know he said, “Oh, it’s just as assessment scale”. Yeah, that’s right, it is an assessment scale, but I think it’s one of the most important assessment scales, for anybody who is in a critical situation. He was downplaying it a little bit, you know, but that’s okay. He clearly ruled out that your mother is brain
dead.
Stephanie: Yep.
Patrik: Which I wasn’t thinking that she was in the first place. You know, I guess he’s not a neurologist, he can’t look too far ahead.
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Stephanie: Right.
Patrik: I’ll tell you what I think the next steps are, it’s too far to look ahead but, once she’s got the PEG, they definitely need to stimulate her a bit more. Like mobilisation, like physical therapy, you know, then the risk is that she may have a seizure, right? That could be a risk. Because now, she’s not
really getting any stimuli, is she?
Stephanie: Exactly, no.
Patrik: Nothing at all.
Stephanie: They said they’d try and move her, the only stimuli she’s getting is movement.
Patrik: Right, right.
Stephanie: They’re not giving her any kind of massages, or anything like that. So, now she’s not getting any kind of extra stimuli.
Patrik: Right. So, that will be the next step, because you know, we mentioned muscle wastage. You know, when somebody is critically ill, and in an induced coma, the muscle wastage goes very quick, and they need to start somewhere. However, what I have seen in the past, that
if you do that in a situation like that, that the risk-
Speaker 4: Infection is great.
Stephanie: Oh okay. Yeah, some leg action. I’m sorry, continue Patrik, I’m sorry.
Patrik: No, no. There is a risk that seizures can be triggered. That will be the challenge. I can see a lot of similarities between your mother’s situation and, I sent you a like earlier this week to a case study, very similar situation. The only difference was, the gentleman at the time did not have
a cardiac arrest, he had a stroke.
Stephanie: Okay.
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Patrik: But at the end of the day, he was neurologically compromised, just as much as your mother. And there was the very same issue, PEG, not waking up, they wanted to ship her out to LTAC, we managed to keep the client in ICU for as long as it took to get him off the ventilator. The client eventually got home, with a trach, but was in a much better position, and never went to LTAC. So, I
can see a lot of similarities there. It’ll really all depend, on the next few days, once she has the trach, you know, can she wake up… you know. And the mobilisation part will be huge.
Stephanie: Yeah because they said that they could, they wouldn’t be happy about sitting up in a chair but, they said lift her arms up and down.
Patrik: Well, besides talking about a trach, have you seen a PEG? Do you know what it looks like? Do you know what it is?
Stephanie: Yes, I do.
Patrik: Right, right. So, a tach-
Stephanie: An airway.
Patrik: Right. A trach is so much… it’s a stable airway, whereas a breathing tube is a very unstable airway. So, it’s much easier and much safer to get somebody out of bed with a trach, right? And once you can mobilise someone, you can build up their strength.
Stephanie: That’s true, that’s right, that’s right.
Patrik: Once of the challenges might be, you know, if she’s not waking up at all, or if the mobilisation is triggering her seizures. That could be a real, that could be a real challenge.
Stephanie: Yeah, yeah.
Patrik: But we can only put on foot in front of the other. There is no point in speculating around what may-
Stephanie: What might be-
Patrik: They need to do the PEG, they need to do the trach and then… need to see what happens next. You know, that’s all… she is stable, she’s off the vasopressors, the kidneys are working. Now that we’ve spoke about the fluid in the lungs, now this often makes sense to me and I think I mentioned it
yesterday, that if they gave the Lasix, she could drop her blood pressure, right? And then she would end up on the vasopressors.
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Stephanie: Mm-hmm (affirmative)
Patrik: Right? They want to avoid the vasopressors as much as possible and I understand that because it’s another complicating sort of issue that she doesn’t need at the moment. Once at the point of weaning off the ventilator, they would need to be aggressive with the Lasix, if it helps her coming off the ventilator.
Stephanie: Exactly. Once they get her on the, once they get her off the ventilator and onto the, what’s the other thing? You call it… the…
Patrik: The trach collar?
Stephanie: The trach. Once they get her on the trach collar then they should be aggressive in getting this lung fluid off her.
Patrik: Very much so, very much so. You know those are all next steps, right?
Stephanie: Mm-hmm (affirmative)
Patrik: This Dr. Brian, is he… he sounds like… is he a junior doctor? Is he young?
Stephanie: Well I have no-, He’s older than me, I’d say.
Patrik: Is he?
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Stephanie: Mm-hmm (affirmative)
Patrik: Okay.
Stephanie: The one you just talked to-
Patrik: Yeah, yeah. Yeah, yeah. Yeah.
Stephanie: He’s pretty junior…
Speaker 4: Come again?
Stephanie: No, no, Dr. Brian, he was just wondering whether he is a resident.
Patrik: So, he’s a senior doctor, is he?
Stephanie: I do not know.
The 1:1 consulting session will continue in next week’s episode.
