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Washington University Experience | VASCULAR | Infarct, watershed | 5A0 Case 5 History
Case 5 History ---- The patient was a 67-year-old man with a history of diabetes, hypertension, hyperlipidemia, coronary artery disease (status post coronary artery bypass grafting in 2000), peripheral vascular disease (status post femoral-popliteal artery bypass grafting in 2001), and prior stroke (lateral medullary syndrome in 2002 with residual left hemiparesis). He called his family on 12/19, complaining of bilateral lower extremity weakness and teeth pain. The family went to his home and found him on the floor due to weakness, but with intact mentation. The patient was admitted to an outside hospital where an MRI showed cortical atrophy and small vessel ischemic changes. He developed hematuria, hematemesis, and was found to have gastropathy and duodenopathy. Lumbar puncture was performed, producing cerebrospinal fluid (CSF) with increased protein (107), increased glucose (90), 4 white blood cells and 5 red blood cells. During the LP he developed respiratory distress, was intubated for airway protection, and transferred to BJH late in the night on 12/23. Dopamine was administered for pressor support (MAP 55 mmHg). EKG showed bigemini that evolved into pulseless electrical activity. The patient coded three times over two hours and received five defibrillating shocks for ventricular tachycardia. He developed renal and hepatic failure and was placed on CVVHD. He also developed a non-ST elevated myocardial infarction with a serum troponin level of 1.3. On neurologic exam, in the setting of sedation, the patient had intact brainstem, reflexes, increased tone and bilateral upper extremities with brisk reflexes, absent reflexes in bilateral lower extremities. In the morning of 12/25, the patient became bradycardic (heart rate in the low 30's), and hypotensive (blood pressure was 50/20), but he responded to atropine and Levophed. At mid-day, the patient once again became bradycardic and hypotensive. The family did not wish for CPR to be performed. He went into pulseless electrical activity arrest and then asystole.
