Hocker, Sara E.

We present an unusual case of a woman in her 30s who was admitted for diabetic ketoacidosis (DKA) in the setting of newly diagnosed but late COVID-19 infection with associated Klebsiella pneumoniae infection. Her altered mental status, out of proportion with her metabolic decompensation, revealed a superimposed cerebral venous sinus thrombosis (CVST) with fulminant cerebral oedema and ultimately brain death. This unusual and fulminant case of cerebral oedema in the setting of COVID-19 infection with bacterial infection, DKA and CVST was the perfect storm with multiple interwoven factors. It offered diagnostic and treatment challenges with an unfortunate outcome. This unique case is a reminder that it is important to consider a broad neurological differential in patients with COVID-19 with unexplained neurological manifestations, which may require specific neurointensive care management.

Background: The majority of patients presenting with acute stroke in teaching hospitals are assessed by neurology residents. Simulation based training has been shown to be an effective teaching tool in medical education. We sought to determine whether simulation based training improves learner confidence in the evaluation and management of acute ischemic stroke. Methods: We devised a simulated acute stroke scenario utilizing a standardized patient instructed to act out a right hemispheric syndrome and an emergency department nurse. Scenarios were performed in May/June of 2013 and April/May of 2014. Laboratory values, vitals, electrocardiogram and a normal head computerized tomography scan were shown to the residents. Residents were expected to efficiently take a focused history, perform an NIHSS exam, evaluate exclusion and inclusion criteria, obtain informed consent for thrombolysis administration and give the correct dose of t-PA. Following t-PA administration, the patient develops an acute severe headache and the learner is evaluated on whether they immediately discontinue the infusion and initiate appropriate management steps for t-PA associated hemorrhage. Following the scenario the learner met one on one with staff for a debriefing session. Learner confidence in the management of acute stroke was assessed before and after the simulation experience using a 5 point Likert scale with 1=novice, 3=competent and 5=expert. Following the simulation, learners were asked to evaluate the experience (poor, needs improvement, good or outstanding). Results: 21 Neurology residents completed the scenario (11 in 2013 and 10 in 2014). Learner confidence improved from mean 2.81(SD-0.88) to 3.36(SD-0.73), p=0.03. Evaluations were favorable with all residents reporting a ‘good’ or ‘outstanding’ experience. Conclusion: We have demonstrated that simulation training in the evaluation of acute ischemic stroke among neurology residents is feasible and improves learner self-confidence.