Case Study: Anoxic Brain Injury

Author: 
Kimberly Kuchinksi, MD, MPH, FAAPMR
Patient:  11-year-old boy with history of congenital heart defect who underwent a palliative surgery for his defect but post-operatively had heart block and went back to the operating room for pacemaker placement. 
 
During surgery the patient had a cardiac arrest and prolonged “down time” with resultant hypoxic ischemic encephalopathy (anoxic brain injury). The acute-care course was complicated by high mechanical ventilator demands, pulmonary embolism, multiple deep venous thromboses, a pericardial effusion and severe vomiting.
 
Length of Stay at GSRH Inpatient Unit: 5 months
 
At admission, the patient was completely dependent for all care. He was not sitting, standing or speaking. He occasionally opened his eyes and withdrew from pain. He had severe flexion contractures of elbows, wrists, fingers and ankles. He had autonomic storming, bladder and bowel incontinence and naso-gastric tube dependence. He was not able to eat or drink anything safely by mouth.
 
Comprehensive inpatient rehabilitation at Good Shepherd’s pediatric unit included: 
  • Physical, occupational, speech and therapeutic recreation therapies (at least one hour each day).
  • Evaluation and treatment by the pediatric neuropsychologist that helped with management and family education. 
  • Medical management for dysautonomia. The patient was weaned dramatically of medications before discharge. We used amantadine to help arouse patient after brain injury. As he improved his level of consciousness, dystonic movements became more prevalent than his spasticity. Treatment with medications helped the patient control upper and lower extremities much better, which helped the patient progress with therapies.
Physical therapists initially addressed contractures with serial casting, DynaSplints, aggressive range of motion and proper positioning. As the patient improved, this evolved to transfer training, then standing in a stander and finally gait training. 
 
Occupational therapists first concentrated on upper extremity stretching and range of motion. As the patient progressed, we worked to improve use of upper extremities, daily ADLs to get the patient participating in care. Ultimately, the patient began working on fine motor skills, self-feeding, card playing and handwriting in preparation for a return to school.
 
Speech-language pathologists (SLPs) worked with  the patient on cognitive and memory skills, as well as oral motor skills and safety with eating. The patient slowly progressed to safe swallowing of purees and eventually to a regular diet with thin liquids. At discharge, the patient no longer required NG tube. 
 
Cognitively, the patient did well with therapy. SLPs worked on regaining speech. Initially, the team was excited for single word utterances. As the patient’s vocabulary expanded, he worked to decrease dysarthria and improve breath support and communication. 
 
At discharge, the patient was able to:
  • Walk with posterior walker 
  • Speak in full conversations with mild dysarthria
  • Play cards, chess and other games 
  • Demonstrate humor 
  • Eat a regular diet with no accommodations and feed himself independently
  • Be completely free of contractures
He was discharged to an outpatient rehabilitation program for daily therapies.
 
Sixteen months after discharge, the patient is able to:
  • Walk independently, without assistive devices or bracing
  • Attend school with an aide for safety
  • Attend therapy only twice weekly
His speech continues to improve. He takes medication for a movement disorder due to ABI and is doing very well with it. According to his mother, he has never stopped progressing. His progress has not plateaued.
 
For information on pediatric, inpatient admissions, call 484-788-5492 or contact us.