1. Lindsay Trantum ACNP-BC VUMC Neurological ICU
Case Study
Lindsay Trantum ACNP-BC
VUMC Neurological ICU

2. 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.

3. 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.

4. What is the most likely diagnosis?
A. Paranoid schizophrenia
B. ICU delirium
C. Altered mental status
D. Sepsis

5. What tests would you order?
A. UA and culture
B. Comprehensive metabolic panel
C. Ammonia
D. Non-contrasted head CR
E. All of the above

6. 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

7. What is the most appropriate pharmacologic intervention?
Lorazepam 2mg IV q2h prn
Seroquel 25mg BID increase by 25mg q12h until desired effect
Haldol 2.5mg q2h prn
Both a and c
Both b and c

8. Case Study
On hospital day 8, Mr. Cam becomes hypoxemic and lethargic. You decide he needs to be intubated.

9. Which sedative would you choose?
a. dexmedetomidine b. Propofol c. Fentanyl d. Versed e. Either a, b or c

10. What interventions will assist you in decreasing Mr. Cam’s delirium?
SBT and assess for extubation daily
Keeping him sedated with fentanyl and versed until ready to extubate
Early mobility
Use of eye glasses and hearing aides
Maintaining a day/night cycle
A, C, D, E
A, B, D, E

11. Identify Mr. Cam’s delirium risk factors
UTI
Intubation/Respiratory failure
Stroke
Electrolyte Abnormalities
Lorazepam administration
All of the above

12. Case Study
On hospital day 11, Mr. Cam is extubated. That evening, he starts picking at his IV sites and pulling on his foley.

13. What is your next course of action?
Versed 2mg IV prn
Re-intubate for his safety
Continue Seroquel and prn haldol
Add dexmedetomidine
Both c and d
None of the above

14. 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.