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
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 Mikaela, as part of my 1:1 consulting and advocacy service! Mikaela’s sister is with a tracheostomy in the ICU and is now off the ventilator. Mikaela is asking about the risks that the ICU team needs to assess before they transfer her sister out of the ICU.
What Are the Risks that the ICU Team Needs to Assess Before They Transfer My Sister with a Tracheostomy Out of the ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Mikaela here.”
Dr. Marie: Some stuff we’ve done. So, do you know anything about what’s happened today?
Mikaela: Just that I think you were doing the Botox thing, because there was a lot of production of saliva or something.
Dr. Marie: Yeah. I’d just come on in the evening and earlier, the consultant who was on in the day, had been to the nurses had noticed her pupils were slightly unequal. They thought that maybe she was doing some sort of rhythmical movements with her arm. So they had some thought on maybe is that a seizure. So they gave her some treatment for that, which..
Mikaela: Was it a Keppra?
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Dr. Marie: … resolved everything and they took her down for a CT head to make sure that she hadn’t had any kind of bleeding or anything like that. Essentially, they said there wasn’t anything on the CT head that explained the seizures. Her brain had changed a bit since her last scan. Her last scan was a while ago.
Mikaela: Yeah, it was a quite a while.
Dr. Marie: The first scan, it was very swollen and tight in her skull. It’s now shrunk quite a lot. They call it atrophy. It’s quite shrunken. But there was no bleeding there and nothing that would obviously explain a seizure. Now, it’s not completely 100% sure whether she had a seizure or not, but I think we did that just to be cautious.
Mikaela: Yeah, so is it Keppra that she’s on now, at the moment?
Dr. Marie: Is it what? Sorry.
Mikaela: Was it Keppra that he had for the seizure?
Dr. Marie: No. So we had some Lorazepam just to stop the seizure at time, but she’s now going to be on Keppra. I think she starts on Keppra too. In case it was a seizure, I think that then acts a sort of preventative measure.
Mikaela: Yeah, because I remember that when she had it the first week round, they had a few instances of it, then it got managed and it was okay.
Dr. Marie: Yeah. The seizures that they have early on, they often settle down and then things happen can happen further down the line. So, I think, we restart that Keppra and see how she goes, really.
Mikaela: Yeah, definitely.
Dr. Marie: She quite often has ectopic beats on her heart and she’s having a few more of those, but we did an ECG and it actually looks the same. We got a cardiologist to look at it. There’s no difference. It’s been steady the whole time.
Mikaela: Because I spoke with the cardiologist yesterday and she was saying pretty much it’s all the same in terms of her heart and how that’s functioning, so you didn’t really have a concern there, to be fair.
Dr. Marie: Yeah. Honestly, my instinct of this is that we’ve done a CT head that’s shown her head. Her brain is a lot less swollen than it was, and unfortunately, obviously she’s not waking up any anymore and that this may be a seizure. It might be just abnormal brain activity. But I think it’s a sign that her brain is very, very severely damaged if her movements that she’s doing appear to be a seizure. But it’s hard to pick between what’s a seizure and what’s just a movement from a very damaged brain. But I think there’s no harming treating her with Keppra, anyway. Restarting that. So, I think we do that.
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Mikaela: In terms of the seizures that she was having, other than the time when it first went in, has she had anything prior to that? Just from today?
Dr. Marie: No. This is the first time. It’s the first time. They weren’t proper big seizures. Like I say, it’s difficult to know whether they were even seizures. It’s certainly very minor. But I think we were probably being pretty cautious, and Keppra’s a drug that doesn’t really have any side effects. So, I think it’s easy for us to start that, just to be sure.
Mikaela: Definitely. Because that’s what you were on, definitely, last time before. The first time.
Dr. Marie: Yeah, it would have been. Yeah. Nothing else has changed. Her breathing’s not changed or anything like that, and her oxygen levels are the same. So, nothing’s really changed. I think it was just us being cautious to a degree. But obviously I think, what this is, is just an indication that her brain is very severely damaged and potentially just… The CT Scan shown that it’s sort of shrunken down and shriveled, for want of a better word, and I think that’s what we’re seeing is just that the process of her brain, its further deteriorating in a way. Dying’s the wrong word because her brain isn’t dead because she’s doing breathing and things like that. But, it’s that similar slow process. But I think we treat those in case they were seizures. But I think my instinct is that they were just funny movements because she’s got a damaged brain.
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Mikaela: Did you happen to do an MRI or anything still just to check that out in detail?
Dr. Marie: No, we haven’t. We haven’t done an MRI. I think that the CT has told us everything we need to know. The CT has shown some very severe damage.
Mikaela: Yeah. It’s just to get a clear understanding of, if you think it was a seizure, then that might be able to, you know.
Dr. Marie: Yeah. The thing is, MRIs won’t show a seizure. They will show that her brain is damaged, the same as the CT, but ultimately, regardless of what’s on her MRI, it’s whether she wakes up is the test. I think the damage to her brain on the CT is the severe enough that we are sure that she’s not going to wake up. And so doing an MRI showing damage exposes her to the risk of going through an MRI scanner. But what does it have? It’s going to show the same as the CT.
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Dr. Marie: MRIs are useful when the CT hasn’t picked up anything and you need more detail. In this case, we know. The CT’s shown us what we suspected and her conscious level matches with that. There’s no need to do extra tests when everything else matches and fits together. It won’t show whether she had a seizure. So, I think we put her on the Keppra. If she has other seizures, we can look at that. But I think I’m pretty skeptical whether it was a seizure at all, if I’m honest. I think it was just her moving in a funny way.
Mikaela: Right, okay. We expected that anyway. The numerous times that we spoke with consultants and stuff, we are to be expecting the involuntary movements. So with the severity of how much brain damage that has occurred. That was something that we took on board and we accepted that that was going to be the case. So yeah. I mean, if it was a seizure or it wasn’t, you don’t know. Anyway, but at least it’s being managed as best as it can be with that medication. In terms of the ward and stuff, do you know what’s happening with that yet?
Dr. Marie: So, because I’ve only been on in the evenings and it’s actually been another doctor’s turn on in the day, I don’t know the full details about it. I know that obviously she’s going to go to a bed that can take tracheostomies. I know that obviously those beds are harder to come by because the wards can only have a certain number of patients with tracheostomies because they need more care. So I think it’s been a process of awaiting one of those beds in an appropriate ward for her, and there are fairly few and far between, and it’s just a case of waiting. I think the cardiologists were going to speak to the neurologists so that the neurologists could, because it’s probably going to be on a neurology ward where she’ll end up going, just so that they’d hand it over to one another about her case. It’s just one of those things that usually takes a little while and it’s not happened right now. It may happen in the days to come though.
Mikaela: Okay, yeah.
Dr. Marie: That’s my understanding of where it’s at for her.
Mikaela: Okay. Yeah, that’s fine. So did she end up having the Botox yesterday then?
Dr. Marie: Do you know, I don’t know, because it’s Simon on day. Let me ask someone that will know. Give me two seconds.
Mikaela: No worries, that’s fine.
Dr. Marie: Yes she did.
Mikaela: Oh, she did. Right. Okay, cool.
Dr. Marie: But you know, that takes like two weeks to kick in.
Mikaela: Oh, really?
Dr. Marie: When it’s on your salivary glands, it takes a good while to start working, that. So, it’s not an instant thing.
Mikaela: How about all the secretions and stuff? Was that still being managed by the nurses? Is it?
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Dr. Marie: Yeah. I’m on the area now and the nurse just suctioned some of the secretions out of her mouth. Hopefully when the Botox kicks in, that will reduce those, yeah.
Mikaela: All right, cool. No, that’s fine.
Dr. Marie: Okay.
Mikaela: I don’t know whether it’s possible to do a Zoom at any point soon. I might have to speak with the nurses.
Dr. Marie: Do you want tonight, you mean?
Mikaela: Yeah.
Dr. Marie: Yeah, yeah. Let me just ask the nurse. One second.
Mikaela: Cheers.
Dr. Marie: Is it okay if her family do a Zoom tonight?
Nurse: Quarter past nine?
Dr. Marie: Quarter past nine, they’re saying.
Mikaela: Yeah, yeah. No, that’s fine.
Dr. Marie: Okay, cool. They’re just going to give her a wash first. Yeah.
Mikaela: Yeah, sure. Cheers for that. I appreciated it.
Dr. Marie: Yeah, no worries.
Mikaela: Bye.
Dr. Marie: All right, cheers. Bye.
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Hi Mikaela,
This is Patrik again. Thank you for this recording with the … I presume it’s an ICU consultant. Mikaela, I’m sorry to hear that your sister had a seizure. Look, I would ask them as a matter of fact, has she been on anti-seizure medications before she had this seizure? It sounds to me like they’ve introduced the Keppra now. It sounds to me like they’ve given the Lorazepam to manage the acute seizure, which makes sense. But I would still ask them, have they given her anything prior to that? Was she on anti-seizure medications before this happened?
The other thing that wasn’t quite clear … it sounds to me like she is off the ventilator as they are waiting for a bed on the ward. I’m not surprised at all that there’s a delay, because as I mentioned before, it’s not as simple as just sending a tracheostomy patient to the ward. They need to make sure they’ve got the staff, they’ve got the skills. The risk for her then to bounce back into ICU is there if they don’t have the skills and if they don’t have the staff on the ward. So there’s certainly a number of risks they need to assess before she’s going. I probably agree with her that an MRI scan won’t give much more conclusions than the CT scan.
Again, I would speak to the neurologist if I was you, because this is clearly a neurology issue, not an ICU issue, the seizures. Next, they are talking about ectopics in the ECG. My first thought there is to make sure they’re checking electrolytes regularly, which is potassium and magnesium. And again, get the cardiologist’s point of view as well, because again, ectopics is a cardiology issue, not an ICU issue. So that would be what I would do if I was you as the next step. Happy to chat this morning. Thank you.
The 1:1 consulting session will continue in next week’s episode.
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Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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