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Patient Care Vignette

MT, an adult female rear-seat passenger, was involved in a motor vehicle crash. The car was impacted on the passenger’s side by a pick-up truck with 1-2 feet of intrusion. EMS found a wildly agitated, screaming, tearful, and non-cooperative patient with an open right femur fracture. The driver was comatose and subsequently intubated for airway control. MT actively resisted interventions precluding easy extrication. Medical Command gave permission for IM sedation and then airway control as needed.

MT arrived in the Trauma Bay intubated. Her injuries included isolated rib fractures (ribs 5-7) and an open midshaft femur (thigh) fracture on the right. No brain injury was noted. Acute operative intervention was undertaken for the femur fracture. While in the operating room (OR), MT’s family was contacted. They disclosed that MT had autism and was principally nonverbal. The driver was transporting her to an adult day program and was not part of the family.

The OR team was unaware of the diagnosis and pursued routine liberation from mechanical ventilation at the end of the case. Non-redirectable agitation led to reintubation and sedation with transport to the ICU for care. Consideration of substance withdrawal was communicated at the patient handoff to explain unexpected and non-redirectable agitation that prompted reintubation. The ICU team explained the new information about MT’s autism to the OR team, and both teams considered the implications of this diagnosis for ongoing care.

The neurodiverse patient population, which includes individuals with dyspraxia, dyslexia, attention-deficit hyperactivity disorder, dyscalculia, autism spectrum, and Tourette syndrome, is rapidly growing globally. While specialized pediatric acute care inpatient facilities are well-equipped to address the medical, surgical, psychiatric, emotional, and psychosocial needs of typical children and adolescents, they may not be equally well-prepared for those with neurodiversity. At even greater risk for being unprepared are adult acute inpatient care facilities. As the neurodiverse patient population ages and crests into adulthood, they are no longer entirely appropriate for pediatric or adolescent-focused facilities. Of necessity, they will require care in an adult acute care hospital (Fig. 22-1). To that end, this chapter explores the unique needs of the neurodiverse population with acute illness to aid facilities in planning, organization, and training to meet anticipated current and future care requirements as well as to support post-ICU recovery. Unlike neurotypical individuals, enabling successful post-ICU recovery critically depends on planning for a successful ICU and acute inpatient course.


Factors Driving Adult Facility Care for Neurodiverse Patients. This figure presents four key factors that are increasing the number of neurodiverse patients within adult facilities, many of whom would have been previously cared for in a pediatric facility. Peds = pediatric acute care facility.

The term “neurodiverse” has supplanted the nonspecific and all-encompassing term “special needs.” The latter term included those with physical limitations and those with cognitive or behavioral ...

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