Session Title: Virtual Poster Hall
Session Time: None. Available on demand.
Disclosures: Elena Nehrbass: No financial relationships or conflicts of interest
Case Description: 21-year-old male was admitted to inpatient rehabilitation on 2/4/2020 in minimally conscious state status post anoxic brain injury after drug overdose . MRI brain showed extensive white matter changes consistent with post-hypoxic leukoencephalopathy. Patient arrived trached, PEGed, status post ECMO, with recurrent fevers attributed to central etiology after repeated workups. Amantadine was started for neurostimulation; he was transitioned to trach collar. On 2/5/2020 he developed tachycardia which resolved with propranolol. On 2/6/2020 his trach was changed to cuffless. Overnight patient developed a fever of 38.3C, tachycardia to 190s, BP 140/104, diaphoresis, sustained clonic posturing, was attempting to bite trach, eyes open but not responsive. Ativan given, RRT initiated sepsis workup. Lactate was 10.7. He was placed on oxygen by trach collar, saturating 97-100%. Trach was deep suctioned with minimal secretions. Propranolol 20mg through PEG given due to loss of IV access. IV access obtained and IVF bolus started. Trach changed to Shiley 4” cuffed, patient placed on vent, femoral central line placed, patient transferred to ICU.
Setting: Model System Urban TBI Unit
Patient: A 21-year-old male with anoxic brain injury secondary to drug overdose. Assessment/
Results: Patient’s presentation was of unclear etiology. Differential included Dysautonomia, Serotonin syndrome, status epilepticus, sepsis. Sepsis workup was unrevealing, patient was transferred back to rehabilitation unit once stabilized.
Discussion: This is a rare case of autonomic storming of such severity in a young patient with anoxic brain injury. It occurred in rehabilitation setting status post downsizing of a trach, and precipitated an emergent transfer. A thorough investigation of potentially contributing factors was conducted (medications, blood work and urine studies reviewed, skin inspected, pain assessed). Dysautonomia was thus attributed to trach downsizing.
Conclusion: This case brings about awareness that severe storming can happen in rehabilitation setting. It can be precipitated by downsizing of the trach, and can occur with delayed presentation.
Level of Evidence: Level V
To cite this abstract in AMA style:Nehrbass E, Escalon M, Naor EH. A Case of Severe Dysautonomia (Storming) in a Young Patient with Anoxic Brain Injury [abstract]. PM R. 2020; 12(S1)(suppl 1). https://pmrjabstracts.org/abstract/a-case-of-severe-dysautonomia-storming-in-a-young-patient-with-anoxic-brain-injury/. Accessed January 24, 2022.
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