Post-Cardiac Arrest: Understanding the Complications of Recovery After Psychosis and Brain Injury
Background: A 49-year-old male with a congenital heart condition known as complete heart block has been reliant on a pacemaker since the age of 19, with his device and leads being replaced in 2015. In recent years, he has been inconsistent with regular medical follow-ups, although he continued his cholesterol medication but neglected his blood pressure treatment. Incident Summary: Last Wednesday morning marked a critical event. The exact duration of his cardiac arrest is unknown, but it is estimated to be under five minutes. Emergency services were contacted promptly, leading to around three minutes of CPR before paramedics arrived, who utilized defibrillation twice to restore his pulse. Upon arrival at the hospital, he was intubated and placed under an intensive cooling protocol aimed at safeguarding his brain during his ICU stay. Although a CT scan conducted in the emergency room yielded normal results, multiple EEGs showed no seizure activity. An MRI could not be performed due to his pacemaker and unstable condition while sedated. By Monday, August 18, he was successfully weaned off sedation and extubated. He demonstrated awareness, albeit with some slowness and confusion, expressing gratitude to visitors, eating and drinking normally, and even requesting personal grooming items. Remarkably, he could identify his caregivers and engage in coherent conversations, recalling their names. However, that evening, despite being administered Benadryl and melatonin, he experienced insomnia. On Tuesday, he underwent an angiogram under fentanyl and Versed sedation, which, according to the medical team, had minimal impact on his consciousness. The angiogram revealed no arterial blockages, prompting a decision to transfer him to a facility equipped for advanced cardiac care, where he could receive a complete pacemaker extraction and replacement with a defibrillator. That night, despite receiving Ambien and trazodone, he continued to struggle with sleep. By Wednesday morning, he exhibited signs of hallucination, consistently recognizing his nurses and maintaining conversations without difficulty, but I sensed a gradual decline in his mental state. Following his transfer to the new hospital that evening, we observed him hallucinating once more, though less severely than earlier in the day. He described events that were untrue, indicating further cognitive deterioration. Upon returning the following morning, it was evident he had not consumed food or liquids. A speech therapist assessed him, discovering he could no longer use a straw, a skill he had managed all week. Unusual tongue posturing was also noted. His ability to communicate had deteriorated, and throughout the day, various physicians assessed his awareness of current time, location, birthday, and name, with his responses becoming increasingly incorrect. We consulted with several specialists including his hospitalist, neurologist, speech therapist, dermatologist due to a rash on his fingers, and psychiatrist. An EEG was performed, and he is currently undergoing a CT scan. In a surprising turn of events, his echocardiogram revealed a return to normal cardiac function, but his scheduled surgery might be postponed due to his mental decline. Conclusion: I understand his brain endured a period of oxygen deprivation, yet I am perplexed that he initially appeared stable upon awakening, only to see his condition worsen over the course of four days. If anyone has experience with similar cases, I would appreciate insights into whether this decline can be attributed to brain injury resulting from his cardiac arrest. Does it resonate that his condition would deteriorate as such post-recovery? Medical professionals are contemplating metabolic causes and psychosis, but it seems they are inclined to attribute the developments solely to the cardiac event, without considering the recent progression of his symptoms. Many thanks for taking the time to read this. Your perspectives would be greatly valued.
Answers (1)
8/22/2025, 12:22:17 AM
OpenHealth AI
It's understandable to feel overwhelmed when navigating the complexities of medical recovery, especially following a serious incident like cardiac arrest. The decline you are witnessing may be related to various factors, including brain injury due to oxygen deprivation, metabolic disturbances, and potential psychological effects from the stress of his condition.
Explanation:
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Hypoxic-Ischemic Injury: After a cardiac arrest, even for a short duration, brain cells can suffer due to lack of oxygen. Initially, a patient may seem stable but, over days, complications can arise as brain cells continue to struggle or swell, affecting cognitive function and behavior.
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Metabolic and Medication Effects: His medical history indicates the possibility of metabolic imbalances, especially given his inconsistent management of blood pressure and cholesterol. Medications, especially sedatives like Ambien and trazodone, can also complicate recovery by causing confusion or hallucinations.
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Psychosis and Delirium: Post-cardiac arrest, patients can experience delirium, a state of confusion and agitation, sometimes leading to hallucinations. This is not uncommon and may be exacerbated by isolation, medications, or changes in environment.
Next Steps:
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Close Monitoring: Ensure he is closely monitored for changes in mental status, nutritional intake, hydration, and medication effects. Regular assessments by a healthcare team can help identify and manage any further decline.
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Nutrition and Hydration Support: Encourage nutrition and hydration—consider working with a speech therapist or dietitian to facilitate eating and drinking safely, especially if he struggles with using a straw or verbal communication.
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Neurological and Metabolic Evaluation: Await results from ongoing diagnostic tests (CT scan, EEG) to assess brain function and rule out metabolic causes. Engaging a neurologist to interpret these findings and consider a comprehensive neuropsychological assessment can be beneficial.
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Engagement and Comfort: Providing familiarity and social interactions can aid in mental stimulation — try to involve family members in his care, as stability in familiar surroundings can help mitigate some psychological effects.
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Medication Review: Collaborate with physicians to review all medications to ensure they align with his current needs and conditions, minimizing sedative effects while managing his symptoms.
This situation requires ongoing support and coordination among healthcare providers and family members for both physical and mental health stabilization. Your involvement is crucial, and advocating for his needs may significantly impact his recovery trajectory.
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7-Month-Old Child with Abernethy Malformation - Exploring Treatment Options
# 7-Month-Old Child with Abernethy Malformation - Exploring Treatment Options ## [7-Month-Old] Identified with Abernethy Malformation (Congenital Portosystemic Shunt) - Treatment Methods? **Age:** 7 months **Gender:** Female **Height:** Age-appropriate **Weight:** Currently 9 kg, was 2.8 kg at birth **Ethnicity:** Asian **Duration of Symptoms:** Present since birth **Location:** Uzbekistan **Pre-existing Health Issues:** Abernethy malformation (congenital portosystemic shunt), liver hemangiomas, chronic jaundice, anemia **Current Treatments:** Supportive management --- ## INITIAL PRESENTATION (June 2025 - July 2025) Our daughter arrived on **June 27, 2025**, presenting with: - Birth weight: **2.8 kg** - Marked jaundice (yellowing of skin and sclera) - Pale or clay-colored stools - **Bilirubin level: 245 μmol/L** (typically <20) An immediate ultrasound indicated multiple liver anomalies, initially thought to be hemangiomas. --- ## FIRST COMPREHENSIVE ASSESSMENT (August 1, 2025 - 1 Month Old) ### Multislice Computed Tomography (MSCT) with 3-Phase Contrast (August 1, 2025): **RESULTS:** - **Portocaval shunt size: 9.9 mm** (blood bypassing the liver into the inferior vena cava) - **Arteriovenous shunt size: 4.4 mm** - **Portal vein size: 6.1 mm** (patent) - **Three nodular cystic lesions** located in the perivascular area, with largest measuring 11.6×20.7 mm, enhancing during the venous phase - Liver features a heterogeneous architecture, exhibiting irregular enhancement - Gallbladder appears elongated and slightly enlarged - Other abdominal organs exhibit normal findings **RADIOLOGIST’S ASSESSMENT:** "Congenital portosystemic shunt indicative of Abernethy malformation; less likely arteriovenous malformation (AVM); cannot dismiss the possibility of localized liver lesions." **ADVICE:** Seek consultations with an abdominal and vascular surgeon. ### Blood Tests (August 1, 2025): **Complete Blood Count:** - WBC: 10.44 × 10⁹/L (normal range) - **RBC: 2.1 × 10¹²/L** (LOW - indicating severe anemia) - **Hemoglobin: 69 g/L** (CRITICALLY LOW; normal is 117-166) - Platelets: 403 × 10⁹/L (elevated) **Biochemistry Analysis:** - Urea: 1.80 mmol/L (normal) - Creatinine: 33.4 μmol/L (normal) - **ALT: >1000 IU/mL** (EXTREMELY HIGH - severe liver dysfunction) --- ## FOLLOW-UP IMAGING (December 16, 2025 - 5.5 Months Old) ### Liver Ultrasound: **RESULTS:** - Right lobe: 64 mm, left lobe: 43 mm - Liver capsule appears irregular and vague - **Parenchyma: heterogeneous, showing 7 hypo-isoechoic nodules** (sizes range from 11.5×10.7 mm to 17.6×15.4 mm) - Capsule features uneven contours - Blood flow noted during Doppler examination - No dilation in intrahepatic bile ducts - **Portal vein: 3.9 mm** (decreased from 6.1 mm - indicating improvement) - Common bile duct: 1.4 mm - Gallbladder: measures 43.7×9.2 mm (pear-shaped, wall thickness 2.0 mm, homogeneous, free of stones) **ULTRASOUND ASSESSMENT:** "Presence of liver volumetric formations (specifically liver hemangiomas)." --- ## LATEST MSCT (February 6, 2026 - 7 Months Old) ### MSCT with 3-Phase Contrast: **FINDINGS:** - Liver remains normal in size, but shows heterogeneous structure with uneven contrast enhancement - **Portocaval shunt: 9.9 mm** (no change, continues to drain directly into the inferior vena cava avoiding liver acinus) - **Arteriovenous shunt: 4.4 mm** (no alteration) - **Three nodular cystic lesions** in perivascular space, maximum size 11.6×20.7 mm, enhancing in the venous phase - **Portal vein: 6.1 mm** (noted during porto-venous phase) - Arteries show no filling abnormalities - Intrahepatic bile ducts remain non-dilated - Gallbladder is elongated and slightly bigger, free from stones - Pancreas: normal - Spleen: measures 66.9×38.5 mm (not enlarged), splenic vein is 3.6 mm - Kidneys: normal placements and structure - No excess fluid detected in the abdominal cavity - No visible changes in lymph nodes **MSCT ANALYSIS:** "Congenital portosystemic shunt indicative of Abernethy malformation, unlikely to be AVM, presence of focal liver lesions cannot be ruled out." **RECOMMENDATION:** Engage with an abdominal and vascular surgeon. --- ## RECENT BLOOD WORK (December 2025 - January 2026) ### Complete Blood Count (January 19, 2026): - WBC: 5.8 × 10⁹/L (SHOWS IMPROVEMENT) - **RBC: 2.93 × 10¹²/L** (IMPROVED but still low) - **Hemoglobin: 72 g/L** (SHOWS IMPROVEMENT but still low) - Platelets: 223 × 10⁹/L (BACK TO NORMAL) - Neutrophils: 30.0% - Lymphocytes: 64.8% - Monocytes: 4.6% ### Biochemistry (January 28, 2026): - Total protein level: 67 g/L (slightly deficient) - Creatinine: 20.7 μmol/L - **Total Bilirubin: 242 μmol/L** (STILL HIGH - unchanged) - **Direct Bilirubin: 142 μmol/L** (VERY HIGH) - **ALT: 50 IU/mL** (DRASTICALLY LOWER from >1000!) --- ## OVERVIEW OF PROGRESS OVER 6 MONTHS | Parameter | August 2025 | January 2026 | Change | |------------------|-------------|---------------|--------------------------| | **Hemoglobin** | 69 g/L | 72 g/L | ↗ Slight improvement | | **RBC** | 2.1 | 2.93 | ↗ Improved | | **ALT** | >1000 | 50 | ✓✓ MAJOR IMPROVEMENT | | **Bilirubin** | 245 | 242 | → Unchanged (still elevated) | | **Portal vein** | 6.1 mm | 3.9 mm (US) | ↗ Decreased | | **Platelets** | 403 | 223 | ↘ Normalized | | **Shunt size** | 9.9 mm | 9.9 mm | → No Change | --- ## CURRENT SITUATION (February 2026 - 7 Months Old) - **Weight:** 9 kg (good growth rate in spite of condition) - **Jaundice:** Continues to be present (yellow skin) - **Stools:** Remain pale/clay-colored - **Development:** Achieving appropriate milestones - **Energy:** Appears to have a good energy level - **Feeding:** Normal appetite --- ## QUESTIONS FOR r/AskDocs We have been informed this is **Type 2 Abernethy malformation** (portal vein present). **Three treatment avenues have been proposed:** ### Option 1: **Endovascular Coil Embolization** (minimally invasive approach) - A catheter is inserted via the leg vein to access the shunt and deploy coils/plugs to close the abnormal vessels - Pros: No surgical incision, minimal discomfort, short hospital stay (2-4 days), no scars, enhanced safety - Duration: 1-2 hours - Recovery: 2-4 weeks for jaundice to show improvement ### Option 2: **Open Surgical Intervention** - An incision in the abdomen to ligate abnormal vessels and redirect blood to the liver - Pros: Direct visualization, effective results - Cons: Surgical scar, longer recovery time (7-14 days in hospital) - Duration: 2-4 hours ### Option 3: **Liver Transplantation** - We have been advised this is not necessary as the portal vein is functional and liver health is improving. --- ## SPECIFIC QUESTIONS TO CONSIDER: 1. **With a functional portal vein (6.1 mm) and improving liver function (ALT normalized), is it advisable to pursue endovascular closure as the preferred treatment?** 2. **Despite ALT levels improving, the bilirubin remains consistently high (242). Should this be a cause for concern? Is there a prospect for it to normalize post shunt closure?** 3. **Are the hemangiomas/nodules (11.6×20.7 mm) linked to the shunt? Will they likely resolve following shunt repair?** 4. **How urgent is the proposed intervention? Is immediate action required, or is there flexibility to wait a few months?** 5. **What complications should we be vigilant for during the waiting period?** 6. **Regarding endovascular closure - what is the average success rate for infants aged 7 months? Are there concerns regarding the shunt size (9.9 mm)?** 7. **The measurement of the portal vein has shown improvement from 6.1 mm to 3.9 mm; should this be perceived as a positive sign or a reason for concern?** 8. **Are there special directives (diet modifications, medications) we should consider while awaiting the procedure?** 9. **Post-procedure, how long should we expect it might take for:** - Normalization of bilirubin levels? - Return of stool color to normal? - Resolution of jaundice? - Regression of hemangiomas? 10. **Can you recommend any specialized centers for pediatric Abernethy malformation treatments? 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