Critical Care / Emergency / Trauma

Act fast when new neurologic deficits arise

neurologic

Elliot Kahn, age 47, is admitted to the hospital with cervical myelopathy and spinal stenosis. He undergoes an anterior cervical exploration and posterior C2-C7 decompression, laminectomy, and segmental instrumentation. He is transferred to the progressive care unit (PCU), where he receives deep vein thrombosis (DVT) prophylaxis with enoxaparin sodium 24 hours after surgery.

History and assessment hints

On postoperative day 1, PCU Nurse Jane Norris reviews Mr. Kahn’s medical history and learns he has had a lumbar discectomy and cholecystectomy but has no significant previous medical history. When she enters his room, he is sitting in a chair with his cervical collar in place. His vital signs are normal, and he has no neurologic deficits.

Call for help

Within minutes of Jane’s initial assessment, the patient states he’s having difficulty moving. When she checks his vital signs and performs a neurologic exam, she finds him hypotensive with a blood pressure of 70/40 mm Hg. His heart rate is 56 beats/minute (bpm) and his respiratory rate is 16 breaths/minute. He is unable to move his arms and legs and complains of numbness in all extremities. However, he isn’t in respiratory distress. Jane calls the rapid response team (RRT) while the charge nurse contacts the on-call neurosurgeon.

On the scene

The RRT nurse arrives within 1 minute and starts mobilizing other team members. Mr. Kahn is alert and able to respond to questions but struggles to stay awake and alert. His heart rate is 86 bpm, with a respiratory rate of 24 breaths/minute and oxygen saturation of 94% on room air. He’s obviously frightened.

Jane, the RRT nurse, a patient care technician, and another nurse on the unit help return Mr. Kahn safely back to bed. The RRT nurse inserts two I.V. lines—one for a fluid bolus and the other for blood withdrawal. An intensivist arrives after being contacted by the neurosurgeon, who’s en route to the hospital.

Mr. Kahn’s symptoms improve somewhat with supine positioning and fluid administration, and he regains extremity movement (scored 2/5). The intensivist orders lab tests and a STAT magnetic resonance imaging (MRI) scan. When the neurosurgeon arrives 30 minutes later, he accompanies the patient to the MRI lab, along with the RRT nurse and intensivist.


After the MRI is completed, the patient’s symptoms return and he can’t move his extremities even while supine. The team immediately reassesses him, and the neurosurgeon calls the surgery department to arrange for emergency cervical decompression. The RRT stays with the patient, then hands him off to the anesthesiologist and surgical staff, giving them a complete report of the sequence of events.

When the MRI reveals an epidural hematoma, Mr. Kahn undergoes hematoma evacuation and laminectomy extension, with administration of fresh frozen plasma to reverse anticoagulant effects. No postoperative enoxaparin is ordered, but DVT prophylaxis is maintained with early ambulation and sequential stockings.

Outcome

After surgery, Mr. Kahn is transferred to the surgical intensive care unit. Two days later, he regains 4/5 functioning of his arms and 5/5 functioning of his legs. He’s transferred to the PCU, where he continues to progress in mobility and ability to perform activities of daily living. After 2 days in the PCU, he is discharged home with normal functioning and requires the usual postoperative follow-up at 1 week. He can anticipate returning to work in 8 weeks.

Education and follow-up

Jane’s quick recognition that Mr. Kahn needed immediate help and her decision to call the RRT proved critical to ensuring a positive outcome. In conjunction with the medical staff, the RRT nurse acted as team co-leader in expediting definitive life-saving care.

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Beverly Marchetti is a neurosurgical/trauma ICU and rapid response nurse team lead at Mission Hospital in Mission Viejo, California.

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