text:  BY SYSTEM  1. NEUROLOGY  Mr. Roach was transported to Intensive Care Unit from the trauma bay . Upon arrival   Neurosurgery promptly placed V. Holtzen bolt . This allowed continuous monitoring of intracranial pressure . Notably   intracranial pressure was 17 when the bolt was placed . During his hospitalization   his intracranial pressure was monitored very closely and maintained to a level of less than 20 . To do this   mannitol 25 mg q. 6h. was used . While using mannitol   his serum osmolalities were followed closely . In addition   to monitoring his intracranial pressure   his systemic blood pressures were maintained in such a manner that his cerebral perfusion pressure was maintained at 70 mmHg . A parameter monitor for his neurologic status PaCO2 which was maintained between 35 and 40 during his hospitalization . Mr. Roach was kept sedated with propofol and was given Fentanyl and    or morphine boluses for pain . Neurologic checks were followed initially every one hour and then every two hours to monitor for change in neurologic examination . During his hospitalization   two subsequent CAT scans were obtained  one on hospital day two . This CAT scan revealed possible worsening and was read as epidural versus subdural bleed . After a discussion with both Radiology and Neurosurgery   the decision was made that the worsening did not appear significant   and this was not accompanied by a change in his clinical condition . His intracranial pressure remained stable   and his clinical examination was unchanged . An additional CT scan was obtained on hospital day three . This examination was unchanged from the previous examination . Again   his intracranial pressure and neurologic examination remained the same   and conservative treatment was opted for . CARDIOVASCULAR  As described in previous section   Neo-Synephrine and eventually Levophed were used to maintain a coronary perfusion pressure of greater than 70 . A pulmonary artery catheter was placed on hospital day four . This catheter was placed when the patient started to demonstrate septic physiology and for increasing pressor support . Please see Infectious Disease section for more details . 3. GASTROINTESTINAL  Mr. Roach was n.p.o. from the time of his admission . A orogastric tube was passed . Initially during admission   carafate was given down the orogastric tube . However   on a routine chest x-ray shot on hospital day three   a mediastinum was noted . This raised the question of potential esophageal rupture . Gastroenterology was consulted for this . Gastroenterology was consulted to assist in creating the most appropriate diagnostic rhythm given his intubated and sedated status . At this point   his carafate was switched to intravenous Protonix and he was strictly n.p.o. 4. HEMATOLOGY  Throughout Mr. Richard admission   his hematocrit remained stable in the low 30s . As will be discussed in the Infectious Disease section   he developed an episode of what appeared to be sepsis   and his white blood cell count peaked at 23 . Mr. Roach was on Pneumo boots spontaneous compression devices for deep venous thrombosis prophylaxis . He was not a candidate for subcutaneous heparin as we were concerned of an intracranial hemorrhage . An inferior vena cava filter was considered but was deferred   as it was felt that Mr. Roach was too unstable to undergo the procedure . 5. ENDOCRINE  Mr. Marian blood sugar was maintained under tight control from 100 to 130 using a regular insulin sliding-scale . 6. INFECTIOUS DISEASE  Mr. Roach had a spike in white blood cell count and developed fevers . His blood urine and sputum were all cultured . Blood cultures were pertinent for one bottle of gram  positive coagulase  negative Staphylococcus which grew from 08-25 . His preliminary cultures including sputum from 08-25 grew Escherichia coli . Sputum from 08-27 grew gram-negative rods   not yet speciated   and from 08-27 a bronchoalveolar lavage grew 1 gram-negative rods and 4 polymorphonuclear lymphocytes . Throughout this time   Mr. Richard temperature continued to increase and was such that on hospital day four   his temperature maximum was 42.2 degrees centigrade . During his hospitalization   his was treated with vancomycin for his gram-negative rods   imipenem   and Flagyl . Initially   he had been placed on clindamycin to cover his drain   but his cultures became positive   and his white blood cell count increased . He was switched from clindamycin to the imipenem and Flagyl . Vancomycin was added when we had the positive blood culture . With a fever of 102   up to 42 degrees centigrade   aggressive measures including cooling blankets   alcohol swabs   and fans were used in an attempt to bring his body temperature down . Hypercarbia would result and increase in cerebral perfusion   paralysis was initiated to decrease genesis of carbon dioxide secreted during shivering . 7. PULMONARY  As discussed in the Infectious Disease section   Mr. Roach developed a pneumonia likely from gram-negative organisms   but most likely from Escherichia coli . For this pneumonia   he was placed empirically on imipenem   vancomycin   and Flagyl . On hospital day three   Mr. Roach had developed an episode of tachycardia and tachypnea . For this   a CT angiogram was obtained which demonstrated no pulmonary embolism . On hospital day four   a routine chest x-ray revealed a left-sided pneumothorax . For this   a left 34 Caucasian chest tube was placed . On the evening of hospital day four   Mr. Roach had an acute episode whereby his central venous pressure rose sharply and immediately followed by a period of asystole . Urgent resuscitation measures were initiated . The measures included attempts at pacing . Epinephrine and atropine were administered as were bicarbonate and calcium . He had a differential diagnosis of asystole preceded by an acute rise in central venous pressure included attention pneumothorax   cardiac tamponade   and pulmonary embolism . During the resuscitation afterwards   it was noted that a patent left chest tube was present in the left chest   so initially neo-decompression was attempted in the right chest . There was no sign of attention pneumothorax with decompression   and a right chest tube was placed . During this time   a needle aspiration of what was felt to be the pericardium was performed revealing bloody fluid coming back . A left anterior thoracotomy was made by the Cardiac Surgery fellow who was present . After 30 minutes of active resuscitation including internal cardiac massage   there was no evidence of return of vital signs or electric activity to the heart as noted on electrocardiogram monitors . Resuscitation was terminated at 1914 on 08-27 . After the termination of resuscitation   both the anesthesia Intensive Care Unit attending and the surgical attending were present to discuss the proceedings events with the patient s family members including his next of kin   his mother . Permission for a postmortem examination was granted . Matthew M. Barnett   M.D. 78 -102 Dictated By  Mark D. Eng   M.D. MEDQUIST36 D  2013 08-28 0021 T  2013-09-03 1111 JOB   24887 Signed electronically by  DR. Katherin Toth on  MON 2013