NCCEd: Neurocritical Care Education for Residents

You follow peripherally. The primary team opts to avoid fever, deferring therapeutic hypothermia. Continuous EEG demonstrates a diffusely slow, disorganized background, with intermittent excess beta activity. There are no state changes or reactivity to stimuli, though the latter hasn't been directly formally assessed.

It's now day 3 of admission, and they ask you to reevaluate the patient. At this point, she remains on propofol and fentanyl gtt. You ask the team to hold these. You go to examine her several hours later. On exam, she is unresponsive to voice and noxious stimuli. Pupils are equal at 4.1mm in diameter, round, and reactive, with NPI > 2 with quantitative pupillometry. She is overbreathing the ventilator. She has extensor posturing in her upper extremities and triple flexion response in her lower extremities.

She undergoes whole-body CT scanning, without any revealing findings. Notably, her non-contrast head CT was unremarkable. Cardiology is consulted, but recommends against left heart catheterization. She is admitted to the medical ICU thereafter. The primary team consults you for post-arrest recommendations and neuroprognostication. On your exam, during which the patient is on propofol gtt and fentanyl gtt, you identify non-reactive pupils, 4mm in diameter each, absent corneal reflex, intact cough reflex, and triple flexion response to noxious stimuli in the extremities.