Wednesday, October 6, 2010

Interesting Case

Warning: This post is will learn a little bit (or a lot!)- with all the case studies I have to write for school, this is actually a real life case from the PICU. I found it interesting, hope you do too!

So the little man I've been taking care of since early summer definitely keeps us PICU nurses and docs on our toes! I worked last Friday with him and we had a typical, fun big events, nothing out of the ordinary.

But then the weekend came....I wasn't there (several of the docs and some nurses said this was why he was "acting up!" apparently I have to be at work 24/7! HA!) Three times over the course of the weekend he had a decrease in his heart rate, his pupils became pinpoint, became unresponsive, and had tons of secretions (the secretions thing is nothing really new though). He got a dose of atropine each time this happened, and it woke him right up...and perked his heart rate right back up to normal.

Of course each of the episodes happened on the night shift, when there is a skeleton crew and less people that "know him" around. So Monday and Tues this week were spent with many consults from the neurologists and autonomic specialists to figure out exactly what's going on.

This little guy, as I've said before, is almost three years old and has what's called Cervical Spinal Stenosis. I know, I know, what is CSS?? Easy definition: the spine in his neck is much more narrow than it should be, causing pressure on nerves that innervate the organs and his arms/legs, not allowing him to move or breath normally (this is why he had to get a trach over the summer). He has had to wear a full upper body brace his entire life, and still has about a year to go until he can get a surgery to hopefully repair the narrowing (stenosis).

So what are these events that keep happening?? Well, along your spinal column you have your Sympathetic Nervous System ("Fight or Flight"- keeps the heart rate up, dilates the eyes, dries up secretions, slows down the gut, etc.) and your Parasympathetic Nervous System ("Rest& Digest"- heart rate decreases, pupils constrict, gut motility increases to digest food, secretions increase, etc.).

Normally the SNS and PNS keep each other in equilibrium so that one doesn't dominate the other. Our bodies typically do a great job of "increasing" one while "decreasing" the other when it's necessary....(for example- the stories you hear of mother's lifting cars off their children r/t adrenaline is possible b/c the SNS kicks in!)

HOWEVER, when you have a little one that has narrowing in his cervical spine, this can compress certain nerves within the SNS or PNS. SO- over the weekend, his PNS "kicked in" more (perhaps his SNS is slightly more compressed recently??) which caused the decrease in HR, pupil constriction, and unresponsiveness.

Now that we know WHY these events are happening, the docs and myself are researching how to best prevent it from happening again. There is not much literature out there on this topic, but it's exciting to be a part of a team trying to improve the quality of this little one's life. Oh, the exciting adventure I get to be a part of as a PICU Nurse! Love it!!

Here's a little "Fight of Flight" humor...just to prove I'm not making this stuff up : )

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