This patient is a 54-year-old homeless man with a history of schizophrenia who presented to the emergency department in November 2020 after being found down with a penetrating injury to the left anterior chest. On arrival, his GCS was 3, and he was being ventilated via bag valve mask by EMS. He was promptly intubated for airway protection. His vital signs were stable. On further exposure, he had an approximately 3 cm stab wound to his left anterior chest, medial to the nipple line, at approximately the level of the 7th rib. Otherwise, he was noted to have ecchymosis of the occiput and superficial lacerations to his right flank. Also concerning was a fixed and dilated left pupil. A pan CT scan revealed a left subdural hematoma with bilateral frontal hemorrhagic contusions and 5 mm of midline shift. Additionally, he was found to have a moderate left-sided pneumothorax and associated left anterior 7th rib fracture for which he underwent chest tube placement with resolution of his pneumothorax (Figure 2). A cerebral oxygenation monitor and drainage device was placed by neurosurgery revealing an elevated opening pressure of 31 mmHg. At this time, there was also concern for possible diaphragmatic injury given the location of his stab wound and imaging findings; however, in the setting of his elevated intracranial pressures, he was deemed unsafe for the OR and admitted to the neuro ICU for further monitoring.
On hospital day 0, his routine workup included a negative COVID-19 nucleic amplification assay. His intracranial pressure was controlled using mannitol and hypertonic saline bullets while he was started on levetiracetam for seizure prophylaxis. Repeat CT imaging the following day showed stability in his intracranial bleeds and a decrease in midline shift. His mental status improved, and he self-extubated on hospital day 3. After his intracranial pressures normalized his drains were removed, and on hospital day 6, he underwent diagnostic laparoscopy to rule out diaphragmatic injury given the location of his initial stab wound. Prior to this procedure, he had a repeat COVID nucleic amplification assay as per institutional policy, which again resulted negative.
Following this intervention, his condition continued to improve. His diet was advanced as tolerated and he was otherwise normalized, although he continued to have issues with agitation and altered mental status secondary to his traumatic brain injury and underlying schizophrenia. Psychiatry was consulted for titration of his medications, and plans were made for discharge to a TBI rehab; however, his discharge was complicated by his homelessness status and frequent behavioral outbursts, occasionally requiring chemical sedation. Beginning on hospital day 13, he was given a one-to-one bedside nursing assistant and was occasionally placed in a SOMA Safe Enclosure bed.
In anticipation of discharge, repeat COVID nucleic amplification assay was done in compliance with rehabilitation center policies. Tests sent on hospital days 49 and 50 both resulted negative; however, an additional test sent on hospital day 55 resulted positive. As before, the patient was given an isolated room and placed on contact, droplet, and airborne precautions. Later that evening, the patient became febrile to 103 F but refused additional fever workup. A second COVID nucleic amplification assay was repeated the following day, which confirmed his COVID-positive status. He was treated with a 10-day course of dexamethasone as per infectious disease recommendations, and his fevers resolved. Repeat COVID testing on hospital day 66 remained positive, and he had his first negative test on hospital day 72. Shortly thereafter, he was accepted to a facility for ongoing rehabilitation.