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SEVERE TRAUMATIC BRAIN INJURY A CASE REVIEW

SEVERE TRAUMATIC BRAIN INJURY A CASE REVIEW. PRIMARY SURVEY. Intubated-not initiating RR Severe dysoxygenation-PaO2 mid 80’s on 100% FIO2 PEEP 14 Extremities cold pale/flaccid; peripheral pulses weak- Temp 32.3 HR 134ST BP 93/66 Pupils 6mm fixed, dilated, non reactive

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SEVERE TRAUMATIC BRAIN INJURY A CASE REVIEW

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  1. SEVERE TRAUMATIC BRAIN INJURYA CASE REVIEW

  2. PRIMARY SURVEY • Intubated-not initiating RR • Severe dysoxygenation-PaO2 mid 80’s on 100% FIO2 PEEP 14 • Extremities cold pale/flaccid; peripheral pulses weak- • Temp 32.3 HR 134ST BP 93/66 • Pupils 6mm fixed, dilated, non reactive • Without corneal reflex

  3. SECONDARY SURVEY • No other obvious trauma • Unknown PMH/PSH/Allergies/Medications • Social Hx: Yale graduate student-english speaking; mother and father live in Japan and speak Mandarin • Non smoker

  4. Recovery From SDH • The mortality rate for patients with an acute SDH ranges from 50 percent to 90 percent. A significant percentage of these deaths result from the underlying brain injury and pressure on the brain that develops in the days after injury. • Approximately 20 percent to 30 percent of patients will recover full or partial brain function. Postoperative seizures are relatively common in these patients. • Favorable outcomes are most common in patients who receive rapid treatment, younger adults, patients with a GCS score above 6 or 7 and reactive pupils, and those without multiple cerebral contusions or unmanageable pressure on the brain.

  5. LAB DATA • WBC 5.2 Hgb 14.0 Plt 269 • INR 1.2 PTT37 • Na 140 K2.5 Cl 109 • Cr 0.6 BUN 12 Glu 238 • ABG: ph 7.15 pCO2 56 PaO2 45 Bicarb 18.8 BE (-) 10.1

  6. ARRIVAL To ICUActive Issues • Severe TBI/s/p Craniectomy • Diabetes Insipidus • SIRS/Distributive Shock • Neurogenic pulmonary edema vs aspiration pneumonia • Severe hypoxia • Pulmonary Edema • Anemia • Thrombocytopenia • Coagulopathy • Metabolic Acidosis • Hypokalemia/Hypernatremia/Hypocalcemia/Hyperglycemia

  7. ICU CLINICAL EXAM • T 30.2 HR132ST BP 94/42 SPO2 67-70% • Pupils 1.5mm B; minimally reactive • Intubated/Sedated on neuromuscular blockade • Lungs rhonchorous • Refractory hypoxia; High PEEP • Mean airway pressures 60’s • Abdomen distended • Extremities Cold

  8. DIAGNOSTIC DATA • WBC 2.2 Hgb 7.7 Plt 80K • INR 2.2 PTT69 Fibrin 91 • Na 144 K3.5 Cl 118 • Osm 339 Ca (i) 0.9 Lactate 5.2 • Echo-akinesis of base (stunned myocardium) EF 30% • PA cath

  9. Understanding Basic’s of Resuscitation • Normal Vital signs DO NOT indicate adequate resuscitation • Low BP associated with worse outcome in TBI • Need to measure Hgb, ABG, Lactate

  10. Understanding Basic’s of Resuscitation • Traumatic blood loss occurs in 5 compartments: chest, abdomen, extremities, retroperitoneum, and outside • Crystalloid and retained intravascular volume is 5:1 • FFP: PRBC ratio- 1:2 • Avoid hemodilution • Measure Ca (i) frequently • Fluid resuscitation strategy evolving science

  11. THE DEADLY TRIAD • ACIDOSIS • HYPOTHERMIA • COAGULOPATHY

  12. MANAGEMENT/DECISION MAKING • Sedated; neuromuscular blockade • Refractory hypoxia; High PEEP; Nitric oxide • Multiple pressors-chronotrophy dependent for cardiac output • Correcting lytes • Bicarb gtt for persistent acidosis • Started on hydrocortisone gtt • Receiving warmed multiple blood products • Warming blanket

  13. Prognosis • VERY POOR • Unable to place ICP monitor d/t emergent closure

  14. 24 Hrs POST INJURYICU DAY 2 • Hemodynamics improving-off pressors and inotropic agents • Swan dc’d • Remains in Pressure Control ventilation With sedation and paralytic on board • ICP bolt inserted for monitoring

  15. 72 Hrs POST INJURYICU DAY 3 • Hemodynamically stable • Remains off pressors and paralytics • Remains on vent support • ICP within target range • Pupils bilaterally reactive • + left corneal reflex • No cough or gag • No response to noxious stimuli

  16. 72 Hrs POST INJURYICU DAY 3 • MRI-suggestive of bilateral anterior communicating artery and significant diffuse patchy damage throughout cortex and deep brain structures • C-spine MRI-without injury

  17. 7 Days Post Injury • Family Meeting Held

  18. 10 Days Post Injury • Trach and Peg placed • Now with cough reflex • Opened one eye • ICP Bolt dc’d • Withdraws extremities to noxious stimuli • On antibiotics for hospital acquired Pneumonia

  19. 22 Days Post Injury • Neuro unchanged • Still with trach/peg • Weaned from Vent • Placed on amantadine and aricept for neurostimulation • Transferred to NSCU

  20. 37 Days Post Injury • Transferred to Yale New Haven Hospital • Neuro unchanged

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