Neurocritical Care

Patient Case

Questions 7 and 8 pertain to the following case.

A 52-year-old woman is admitted to your ICU after a single-vehicle crash. She has many orthopedic injuries to

her lower extremities and a subdural hematoma, which will require an emergency craniotomy for evacuation.

Her home medications include metoprolol, rivaroxaban 10 mg (last dose 5 hours ago), lisinopril, and atorvas-

tatin. Her medical history is significant for atrial fibrillation. Laboratory values on admission were notable for

Hct 31.2% and Plt 577,000/mm3.

Which laboratory test would have the capability of assessing whether or not the patient was taking their

rivaroxaban?

Which therapy would be most appropriate to reverse rivaroxaban before this patient’s emergency craniotomy?

Diagnostic tests

The American Spinal Injury Association (ASIA) Impairment Scale is a helpful guide to understanding

an injury. It was developed by doctors at the ASIA to categorize the extent of an injury in terms

of the degree of damage to the spinal cord. If the injury is “complete,” (ASIA A) it means that no

messages can travel across the location of the injury to the brain. However, “incomplete” injuries,

which mean that some messages can still transmit, are classified as ASIA B, ASIA C, or ASIA

D, depending on amount of movement and feeling that remain below the level of the injury. The

classifications are as follows:

ASIA A: Complete, no motor or sensory function is preserved below the level of the injury,

including the sacral segments S4–S5

ii.

ASIA B: Incomplete Sensory, but no motor function is preserved below the neurological level

of injury, and includes the sacral segments S4–S5

iii.

ASIA C: Incomplete, motor function is preserved below the neurological level of injury, but

more than half of the key muscles below the level have a muscle grade less than 3 (i.e., unable

to move against gravity)