Head Injury Patient Hot Case

GENERAL APPROACH

• Isolated TBI or not
• Phase of illness:
  — < 48 hours
  — day 2-7
  — late
• Complications:
  — refractory intracranial pressure, VAP, nosocomial infection, ventriculitis

INTRODUCTION

CUBICLE

• long/short stay
• cooling device: refractory ICP

INFUSIONS

• vasopressors: haemodynamic augmentation for CPP
• sedatives
• neuromuscular blockade for management of shivering during cooling
• phenytoin: seizure prophylaxis
• hypertonic saline
• thiopentone infusion: refractory ICP management

 VENTILATOR

• mode
• level of support
• level of oxygenation: FiO2, PEEP (high with chest injuries, aspiration, nosocomial pneumonia, ARDS)

MONITOR

• ICP monitoring: pressure, character
• CPP: >60mmHg
• arterial trace: MAP, swing, pulsus paradoxus, pulse pressure
• ETCO2: 30-40mmHg satisfactory, ask to correlate with a recent PaCO2
• temperature: cooling to < 38.5 C commonly performed if ICP uncontrolled
• CVP: number, waveform

EQUIPMENT

• EVD: CSF pressure prior to drainage, colour, frequency and volume
• Codman:
• EEG: burst suppression if thiopentone required
• tracheostomy
• IDC: colour, volume – jugular venous bulb monitoring

QUESTION SPECIFIC EXAMINATION

• neurological -> head: EVD, craniotomy, midline, 30-45 degrees head up, no neck compression, wounds

-> BOS #: CSF, haemotympanum, otorrhoea, rhinorrhoea, racoon eyes, Battle’s sign
-> unconscious
-> conscious

• hands/arms -> head -> chest -> abdo -> legs/feet -> back (secondary survey)

-> general:
-> cardiovascular:
-> respiratory:
-> abdominal:

• asked to see CT and angiography results
• relevant primary or secondary insults

RELEVANT INVESTIGATIONS

• CT head
• CXR
• electrolytes: paired plasma and urinary
• other organ failures (hepatic and renal)
• ABG: gas exchange, metabolic state

OPENING STATEMENT

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• isolated TBI or not
• phase of illness
• complications