Lvad patient passed away from massive hemorrhagic stroke.Summary below: elderly male presenting with ams.Last well known around 12pm.Has been hallucinating for the last day or two per wife.Ate lunch today.And then fell asleep in his chair.Found unresponsive and breathing funny around 7:30pm.On arrival patient has a roving gaze.Right pupil is abnormal in shape and dilated.Left pupil is round and small.Both non-reactive.Withdraws from pain in ble.Decorticate posturing in bue.Lvad in place.Coarse bs throughout both lung fields.Mdm.Patient is a 66-year-old male with a history of chf, prior mi with lvad placement on warfarin who presented to the ed via ems with concern for patient being found unresponsive.Patient was last seen normal at approximately 12 pm today.Patient with anisocoria and roving gaze.Gcs 3.Decorticate posturing in all extremities.Patient lvad device auscultated.Breath sounds present.Patient intubated given probable clinical course and need for ct scan.Intubation note as noted below.No immediate complications.Patient then sent for ct scan where he was noted to have a large hemorrhagic stroke.Ct: there is an 8.8 x 4.5 x 6.5 cm intraparenchymal hematoma in the right temporal/parietal/frontal/occipital lobes with intraventricular extension.There is a severe amount of adjacent vasogenic edema.There is hyperdense blood present in the right lateral ventricle, third ventricle, cerebral aqueduct, and in the fourth ventricle as well as in the foramen of luschka bilaterally.Small amount of blood is also present in the left lateral ventricle.There is a 3 mm thick medial left frontal convexity subdural hematoma.There is approximately 1.9 cm of leftward midline shift as well as inferior transtentorial herniation on the right.Moderate hydrocephalus of the left lateral ventricle.There is effacement of nearly all of the right hemispheric sulci.Patient was on warfarin due to lvad placement and has an inr of 5.2.A few days ago was 3.Patient reportedly feeling depressed for the last few days and has not been eating.Could be cause for increased inr.Otherwise patient noted to be normoglycemic.Did have aki present.Hyponatremia, however not likely cause of ams given large hemorrhagic stroke.Patient family updated of large hemorrhagic stroke and that this will be a nonsurvivable insult.Wife agrees to move patient to comfort care.Given that the patient has lvad placed, lvad department contacted about how to disconnect lvad.Waited for family to arrive to hospital to say goodbyes.Fentanyl and versed given for comfort.Subsequently walked through lvad disconnection.After lvad disconnected, patient died within a minute.Patient nonresponsive pupils, no reaction to pain, no heart or lung sounds auscultated.Patient family at bedside.Final diagnoses: hemorrhagic stroke (hcc-cms).A total of 60 minutes critical care time spent in the management of this patient.This involved close hemodynamic monitoring, multiple bedside re-assessments, medication administration and consultations.
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