+ What are the key components of this patient’s history and physical examination?

Relevant History:

• What are the circumstances surrounding the patient’s TBI (mechanism of injury, time since injury, other concomitant injuries).
• Describe the patient’s hospital course?
• Describe the patient’s recent neurologic status. Is there evidence of sleep-wake cycles or eye opening? Has she followed any commands? Are there any spontaneous or purposeful movements? Has she vocalized?
• Describe recent imaging?
• Recent vital signs?
• Does the patient appear to be in pain?
• Past medical and surgical history?
• Family history?
• Current medications?

Relevant Physical Examination:

• Vital signs?
• General appearance?
• Arousal (is the patient attentive; are her eyes open with or without stimulation?)
• Communication (any attempts at intentional communication?)
• Command following?
• Verbalizations or oral movements?
• Movement of extremities (spontaneous or purposeful?)
• Object use?
• Visual pursuit, fixation, or startle?
• Withdrawal to pain?
• Within the limits of command following, cranial nerve examination, manual muscle testing, sensory examination?
• Reflexes and tone/spasticity?
• Additional examination: heart, lungs, abdomen, extremities, skin

+ What is your differential diagnosis for this patient's tachycardia?

• Infection/sepsis (commonly pneumonia, urinary tract infection, bacteremia, intracranial infection), venous thromboembolism (DVT or PE), pain, volume depletion, anemia, cardiac abnormality such as atrial fibrillation or SVT, hypoxia, paroxysmal sympathetic hyperactivity (storming), medication-induced (stimulants), hyperthyroidism, withdrawal.

+ What initial tests would you order to workup the tachycardia?

• The patient is unable to provide a history, so a broad workup would be appropriate. CBC, CMP, TSH/T4, urinalysis, blood cultures, and chest x-ray should be considered first. Depending on the clinical context, I would also consider ordering troponin and d-dimer levels as well as CT or MRI of the brain. I would also consider doppler ultrasound of the lower extremities or CT chest with contrast to evaluate for venous thromboembolism.

+ How would you manage this condition?

• I would maintain three major goals in treating paroxysmal sympathetic hyperactivity: identifying predisposing factors, stopping excessive sympathetic outflow, and supportive management. I would attempt to identify and eliminate any potential triggers such as pain, underlying fracture or venous thromboembolism, or infection. Depending on the patient’s clinical profile, I would consider medications including propranolol, bromocriptine, clonidine, dantrolene, baclofen, and benzodiazepines. Refractory symptoms may require intravenous infusions. Supportive therapy includes cooling blankets for elevated temperatures, optimizing nutrition and hydration, and pain management.

+ Challenge Question

• What is propranolol’s mechanism of action and how might it be helpful in treating paroxysmal sympathetic hyperactivity?

+ Challenge Answer

• Propranolol is a beta blocker, so it can be helpful for control of hypertension and tachycardia associated with PSH. It is nonselective and lipophilic, easily crossing the blood-brain barrier and mitigating excessive sympathetic outflow.

+ How would you approach this discrepancy?

• I would begin by reviewing the number of recent DOC referrals and comparing them to historical referral numbers to determine if and when the number of DOC referrals had dropped. I would consider various reasons for the drop in referrals, including a lack of primary team awareness of PM&R DOC management, fewer patients with DOC being admitted to the hospital, or perhaps purposeful omission of referrals due to lack of trust or confidence from the primary team. I would reach out to the primary teams and make them aware of my ability and desire to help manage DOC in the acute care setting. If appropriate, I might ask them why there have been fewer referrals recently. Regardless of the reason, I would put full effort into all DOC referrals and would provide clear and concise recommendations in order to build trust from primary teams and to provide the best possible patient care.

+ What is your response?

• A good response would be:

  “Thank you for reaching out regarding this patient; I always appreciate discussing these decisions in person or over the phone so that we can hear each other out. I agree with you that the patient has certainly shown neurologic improvement since admission, but as you know she remains in a minimally conscious state and it is very difficult to predict her recovery trajectory going forward. In my experience, these patients often take weeks to months -- if not longer -- to regain good enough swallow function to take in 100% of their nutrition and hydration by mouth. A PEG tube will reduce caregiver burden and will reduce the risk of nasal mucosa breakdown. Placing a PEG tube prior to her rehabilitation admission will allow her to spend her time at rehabilitation engaged in therapies aimed at promoting functional recovery. Will you please reconsider placing a PEG tube prior to inpatient rehabilitation?”

• Note: You will need to be firm but not adversarial. You should acknowledge that prognostication is difficult in DOC but that the chance of sufficient recovery of swallow function in a short time frame is low. As a consultant, it is not your place to make the final decision to place or not place the PEG tube. However, as a gatekeeper responsible for clearing admissions to the inpatient rehabilitation unit, you do have the ability to deny an admission unless appropriate criteria are met, including PEG tube placement in certain patients.