OpenHealth Q&A

Strategies to Mitigate the Risk of Aspiration in High-Risk Patients

### Can Fatal Aspiration Have Been Avoided in a Patient with TBI? **Patient Overview** **Age:** 76 **Gender:** Male **Primary Diagnosis:** Traumatic Brain Injury (TBI), complicated by evolving intracranial hemorrhage and cerebral edema **Outcome:** Cardiac arrest attributed to suspected aspiration, leading to death despite multiple resuscitation attempts The patient had a notable cardiovascular history, including a stent placed five years earlier and bypass surgery performed seventeen years prior. ### Medical History Timeline **Initial Hospitalization (Day 1 to around Day 15):** - The patient was admitted after sustaining a fall resulting in TBI, alongside a minor initial brain bleed. - The condition of the brain bleed deteriorated further, causing cerebral edema and hemorrhagic contusions. - Neurological status showed variability; although the patient was intermittently disoriented and delirious, there were signs of improvement. - Additional complications included orthostatic hypotension, low sodium levels (hyponatremia), malnutrition, and notable weight loss. - Subsequently transferred to a rehabilitation center to initiate recovery efforts. **Second Hospitalization (approximately Day 16–20):** - Shortly after entering rehabilitation, a new CT scan indicated an escalation in cerebral edema and hemorrhagic contusions. - Plans were implemented to administer hypertonic saline to enhance sodium levels and facilitate re-hospitalization. - The swallowing assessment indicated the patient could consume bite-sized foods; however, he exhibited a poor appetite and reluctance to hydrate. - Persistent disorientation remained, although he occasionally recognized his surroundings (hospital); there was a strong desire to leave the hospital, and he appeared to improve. **Day Prior to Demise (approximately Day 19):** - Family members were involved in oral feeding, though the patient continued to have a poor appetite and lost weight despite encouragement to eat more. - Following a somewhat forceful feeding effort, the patient vomited; later attempts with applesauce also resulted in vomiting. - **Sodium levels returned to normal, and hypertonic saline administration was halted.** - Vomiting persisted throughout the night, even after receiving anti-nausea medication and hydration, ultimately leading to an NPO (nothing by mouth) status being initiated. - Observations included complaints of shortness of breath, diminished responsiveness, and reduced verbal communication. - An EKG and CT scan were conducted in the evening: brain injury remained stable but still indicated edema; EKG results were normal. - Physical examination yielded unremarkable results, with a soft abdomen and stable vital signs; bowel movements were regular. Aspiration was not initially suspected, though a gastrointestinal ailment was considered. - **During this time, no significant escalation in care or respiratory examination occurred. The patient remained on a general monitoring floor.** **Day of Demise (approx. Day 20):** - The patient vomited early that morning, leading to observed low oxygen saturation and cyanosis by the one-to-one aide; initially thought to be a monitor error until another episode of vomiting occurred, resulting in cardiac arrest. - CPR was administered for 22 minutes, achieving return of spontaneous circulation (ROSC) and correcting electrolyte imbalances. - There were multiple arrests thereafter, and the decision was made to permit a natural death. - Vomitus was noted during resuscitation efforts — the official cause of death was ascribed to aspiration. Despite uncertainty surrounding the circumstances of death, the attending physician advised against an autopsy. **Questions for Consideration:** - Was the forceful feeding a contributing factor to the initial episode of vomiting? - Could healthcare professionals have taken measures to avert the fatal aspiration incident? - Were there any alternative actions that might have made a difference? It is deeply unsettling, especially since he was on the path to recovery and was anticipated to return to rehabilitation once his sodium levels stabilized (which they did, just a day before he passed away).

Answers (1)

12/16/2025, 5:01:26 PM

OpenHealth AI

I'm very sorry to hear about this situation; it must be incredibly difficult for the family and loved ones involved. The circumstances surrounding fatal aspiration in patients with traumatic brain injury (TBI) can indeed be complex and tragic. Here are some key points and considerations regarding how aspiration might have been mitigated and what could potentially be learned.

Key Points:

1. Risk Factors for Aspiration in TBI Patients: Patients with TBI often experience dysphagia (difficulty swallowing), disorientation, and changes in consciousness, which increase the risk of aspiration.

2. Feeding Strategies: The forceful feeding may have contributed to the vomiting episodes, which can lead to aspiration if regurgitated contents are inhaled into the lungs.

3. Monitoring and Response: Adequate monitoring of swallowing ability, especially post-feeding, is crucial in high-risk patients.

Actions That Could Have Helped Mitigate Aspiration Risk:

1. Careful Assessment of Swallowing:

• Tailored Feeding Plans: Incorporating a more stringent evaluation of his swallowing skills before and during feeding, possibly utilizing a speech therapist for guidance.
• Gradual Introductions: Start with easier-to-swallow foods, like purees, and proceed to more complex textures with professional supervision.

2. Reassessing Feeding Techniques:

• Avoid Forceful Feeding: Feeding should be gentle, allowing for breaks and ensuring the patient is ready to swallow before each bite.
• Upright Positioning: Patients should always be kept in an upright position during and after feeding to help prevent aspiration.

3. Increased Monitoring:

• Close Observation After Feeding: Implementing a protocol for monitoring patients closely after meals to observe for any signs of difficulty or distress.
• Immediate Response Protocol: Engaging a rapid response team for any episodes of vomiting or irregularities in oxygen saturation.

4. Nutritional Support:

• Nutritional Consult: Address malnutrition proactively with the help of a dietitian who can recommend suitable alternatives and nutritional support methods.

5. Informed Family Participation:

• Education for Family Members: Providing guidance to family members regarding safe feeding techniques and what signs to look for during meals.

Conclusion:

While there are no guarantees in complex medical situations like this, implementing a thorough, multi-disciplinary approach can significantly reduce aspiration risk in TBI patients. Continued education, assessment, and monitoring can vastly improve outcomes.

If you or others have further concerns about this case, it might be helpful to discuss with healthcare providers who specialize in critical care and rehabilitation for more tailored insights and preventive strategies. This experience can also be shared with advocacy groups focusing on patient safety for TBI patients to improve protocols widely.