A case of hypoxic ischemic encephalopathy

Hypoxic ischemic encephalopathy

Hanifa^1*, Christine Rajathi², Subathra Devi. M³, Maha Lakshmi⁴

¹Senior Staff Nurse, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse In-Charge, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

⁴Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence

Abstract

This case describes a 56-year-old female with known diabetes mellitus and hypertension who presented with breathing difficulty, sweating, and productive cough. She developed cardiac arrest and required cardiopulmonary resuscitation and mechanical ventilation. Further evaluation revealed myocardial infarction with triple vessel disease, and she underwent successful percutaneous transluminal coronary angioplasty with stenting. Post-procedure, the patient developed recurrent seizures and reduced consciousness.

Key words: Cardiopulmonary resuscitation; Cardiac arrest; Comorbid conditions

Introduction

Cardiac arrest and myocardial infarction are major causes of mortality and can lead to severe neurological complications due to reduced oxygen supply to the brain. Patients with comorbid conditions such as diabetes and hypertension are at increased risk of cardiovascular and cebrovascular events. Post-cardiac arrest patients often develop complications such as stroke, seizures, infections, and prolonged ventilator dependency. Early diagnosis, prompt interventional procedures, multidisciplinary critical care management, and continuous neurological monitoring play a vital role in improving patient outcomes and reducing long-term complications.

Case presentation

A 56 years old female with diabetes and hypertensive had a complaint of breathing difficulty and NYHA IV since 27.10.2025 associate with sweating cough with expectorant in which she treated in local hospital where she had a cardiac arrest, 2 cycles of CPR given and intubated and put on mechanical ventilator.

Social History: She does not have any social history

Allergies: No known medicine or environmental allergies

Past Medical History: No past medical history

Physical Examinations

The patient was on ventilator support

Vitals

PR	88/min
BP	160/80 mmHg
Temp	99F
SpO2	99% with 60% FiO2
RR	16/min
GCS	E4 V4 M6
CS	S1S2 (+)
RS	B/L AE (+)
P/A	Soft
CNS	NFND

Relevant Investigation

Total WBC Count	8420 Cells/Cumm
Platelet Count	183000 cells/µl
Absolute Lymphocyte Count (ALC)	1360 cells/µl
Eosinophil	10.90%
Basophil	0.20%
Absolute Monocyte Count (AMC)	830 cells/µl
Absolute Neutrophil Count (ANC)	5290 cells/µl
Mean Platelet Volume (MPV)	11.8 NA
Neutrophil	62.80%
Monocyte	9.90%
Total RBC Count	2.51 ML/10^9
C Reactive Protein (CRP)	106.73 mg/L
(MCHC) Mean Corpuscular Haemoglobin Concentration	31.0 g/dl
Procalcitonin	2.97 ng/mL
Absolute Basophil Count (ABC)	20 cells/µl
Lymphocyte	16.20%
Packed Cell Volume (PCV)	21.00%
Absolute Eosinophil Count (AEC)	920 cells/µl
RDW - CV	19.10%
Urea Serum	68.48 mg/dL
Epithelial cells	01-Feb
Bicarbonate	31
Alanine Aminotransferase (ALT/SGPT)	31.9 U/L
Albumin, Serum	3.61 g/dl
Direct Bilirubin	0.32 mg/dL
Total Bilirubin	0.69 mg/dL
Globulin	2.50 g/dl
Aspartate Aminotransferase (AST/SGOT)	106.7 U/L
Gamma - Glutamyl Transferase (GGT)	37 U/L
Alkaline Phosphatase	72.9 U/L
Potassium	3.29 mmol/L
Sodium	154 mmol/L
Indirect Bilirubin	0.37 mg/dL
Total Protein	6.11 g/dl
Chloride	115 mmol/L
A/G Ratio	1.44.
Albumin Urine	Present (+)
Urine Specific Gravity	1.02
Urine Reaction	5
Urine Glucose	Nil
Blood Ketone (POCT)	<0.01
RDW - CV	18.10%
Absolute Eosinophil Count (AEC)	150 cells/µl
Packed Cell Volume (PCV)	31.00%
Lymphocyte	18.70%
Absolute Basophil Count (ABC)	0 cells/µl
(MCHC) Mean Corpuscular Haemoglobin Concentration	32.6 g/dl
Haemoglobin	10.1 g/dl

Culture Reports

Blood	Sterile after 3 days 13/11/2025
Urine	No growth 6/12/2025
Tracheal	No significant growth19/11/2025
Stool	Clostridium difficile antigen and toxin are negative on 24/11/2025

Radiology investigation

Multifocal acute infarct bilateral parietal, right frontal and periventricular cortex
Diffuse cerebral atrophy. Small vessel ischemic disease

Diagnosis

Hypoxic ischemic encephalopathy
Acute ischemic CVA – cardio embolic stroke
Status epilepticus
Sepsis – Acinetobacter SPP (MDR) / staphylococcus aureus (MRSA)

Management

She was admitted under cardiologists and diagnosed as MI managed as IW PWMI CAG done for the patient and found to have triple vessel disease and advised PTCA and underwent elective PTCA with stenting to proximal to mid RCA & mid to distal RCA with successful result. Post cardiac arrest, she was in poor sensorium with recurrent episodes. Neurologist opinion obtained and managed. The patient was extubated and IABP removal was done in view of persisted seizure activity MRI Brain was taken for patient it showed acute infarct MCA territory and bilateral fronto parietal cortex minimal mass effect and diffuse cerebral edema, cardio embolic etiology was considered.

Started on dual antiplatelet again patient was re-intubated due to recurrent seizure activity followed by poor GCS & aspiration risk, one unit of PRBC transfused for HB drop and ET culture and sensitivity showed MDR /MRSA& MDR Acinetobacter and antibiotics were escalated. Patients were shifted to neuro specialty ICU for further management. She was treated with antibiotics, AEDs, neuroprotective, PPI, dual antiplatelet, stain, diuretics, antihypertensive drugs, anticoagulants, inotropes and other supportive measures.

Physiotherapy continued including high sitting &chair sitting exercises and all EEEG taken and cardiology review for post cardiac procedure and ENT review for tracheostomy since patient had hypoxic bradycardia due to poor airway functioning. Electrolytes were corrected. Patient invasive lines were changed due to fever spikes. GCS remained static (E2 M3V t) overall prognosis remained guarded. The patient is weaned from the ventilator to tracheolife and discharged from hospital with homecare nurse.

Outcome

The patient tolerated the T-piece with oxygen support; oxygen was gradually tapered. Overnight, the patient tolerated BIPAP, and weaning continued. Trachoelife with cuff inflated was initiated on 20.12.25. Physiotherapy continued and tracheostomy care and bedsore care were maintained. She is being discharged at request with home nursing care.

Nursing Management

Neurological Monitoring

Monitored GCS, pupillary size, equality, and reaction to light, headache, vomiting
Observed motor responses and deterioration

Airway and Oxygenation Management

Maintained patent airway and ensure adequate oxygen delivery
Performed suctioning only when necessary using aseptic technique, to prevent hypoxia

Positioning and ICP Control

Maintained head-end elevation at 30 degrees, head and neck in neutral alignment
Reposition done the patient every two hours
Provided pressure injury prevention measures
Performed passive range-of-motion exercises

Seizure Precautions: Observed continuously for seizure activity

Hemodynamic and Vital Signs Monitoring

Monitored blood pressure, heart rate, respiratory rate, and temperature
Immediately reported hypotension, hypertension, or hyperthermia

Fluid, Electrolyte, and Nutrition Care

Monitored intake and output accurately
Observed for fluid overload or dehydration
Initiated enteral feeding as prescribed and maintaining aspiration precautions

Infection Prevention

Maintained strict aseptic techniques during all procedures
Monitored for signs of ventilator-associated pneumonia, urinary tract infection, or sepsis

Discharge medications

S.no	Drug name	Strength	Frequency	Route of admin	Relationship with meal	Days

1	Tab. Phenytoin	100mg	TDS	RT	After food	3 weeks
2	Tab. Pantocid	40mg	OD	RT	Before food	3 weeks
3	Tab. Levipil	1gm	BD	RT	After food	3 weeks
4	Tab. Tonact	40mg	OD	RT	After food	3 weeks
5	Tab. Fexanto ER	40mg	OD	RT	After food	3 weeks
6	Tab. Nicardia	10mg	TDS	RT	After food	3 weeks
7	Tab. Torplat	90mg	BD	RT	After food	3 weeks
8	Neb. Duolin	-	TDS	P/TT		3 weeks
9	Neb. Budecort	-	BD	P/TT	-	3 weeks
10	Neb. Ciplox D	-	BD	P/TT	-	5 days

Provided emotional support to patients and family

Education given to home nurses regarding condition, tracheostomy, and suction needs

Conclusion

Hypoxic cerebral encephalopathy remains a significant cause of neurological morbidity following hypoxic–ischemic events. Timely diagnosis, aggressive stabilization, and evidence-based medical and nursing interventions are essential to limit secondary neuronal injury and optimize neurological recovery. Comprehensive nursing management, including vigilant neurological monitoring, maintenance of oxygenation and hemodynamic stability, prevention of complications, and early initiation of rehabilitation, plays a pivotal role in improving patient outcomes. A multidisciplinary and patient-centered approach is fundamental to enhancing survival, functional recovery, and long-term quality of life in patients affected by hypoxic cerebral encephalopathy

A case of hypoxic ischemic encephalopathy

Hypoxic ischemic encephalopathy

Hanifa1*, Christine Rajathi2, Subathra Devi. M3, Maha Lakshmi4

Nightingale Journals

Hanifa^1*, Christine Rajathi², Subathra Devi. M³, Maha Lakshmi⁴