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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | Head Injury Patient Hot Case

Head Injury Patient Hot Case

by Chris Nickson, Last updated December 7, 2012

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

=

  • isolated TBI or not
  • phase of illness
  • complications

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About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

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