Take the Critical Care Challenge

Posted by Jennifer Zeis • May 15th, 2014

After transfer to a surgical floor following a long ICU stay for septic shock and complications, our patient, a frail 77-year-old man, is found on the floor, unable to speak, and with decreased movement on the right side. CT reveals acute subdural hematoma, hemorrhagic contusion, and displacement of midline intracranial structures. What is the most appropriate management of this patient’s traumatic brain injury?

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15 Responses to “Take the Critical Care Challenge”

  1. after the initial ABCDE assessment, surgical evacuation( burr hole insertion/craniotomy) depending on the size of the bleed, stopping any meds which might worsen the prognosis, ie. CLEXANE, blood films looking for causes of the CVA, and MRA/MRI, bubble ECHO, subsequently followed by close observation and neurorehab.

  2. Ali Kenawi says:

    Drainage

  3. Adolfo Vázquez says:

    What kind of ICU leve a patient alone, to permit this trauma!?!?
    The patient need a surgícal evacuation by craniotomy.

  4. miguel angel hernandez castro says:

    This patient, needs measurements of basic life support, after attention by neurosurgery for hematoma evacuation.

  5. Laura says:

    Was anyone else’s first thought palliative care for the poor gentleman who has already been through a lot?

  6. S. Schoen says:

    I have to disagree with the comment above. In case of an acute subdural hematoma the surgical procedure changes dramatically as the pathophysiology is different. The subdural hematoma and the hemorrhagic contusions implicate a major TBI, most likely from a fall on the floor. She should be rushed asap to the OR for a large hemicraniectomy on the side of the hematoma, presumably the left side. If the patient is still in the CT gantry, I would also go for a CTA, otherwise not. As for the TBI I would also place an intraparenchymal pressure probe to monitor here ICP after surgery.
    Stop all medication which could increase bleeding risk.
    Postoperatively delayed extubation attempt on intensive care unit if ICP is normal.

    If initial GCS was low when patient was found and/or pupill aymmetry was present, I would discuss stop of treatment with relatives immediately before going for surgery.

  7. Pranav Singh says:

    Patients age and underlying critical illness portend a poor prognosis. His advance directives need to be clarified with the power of attorney before any further intervention.

  8. Alap Shah says:

    First, talk to his POA/surrogate/family about prognosis and advanced directives, given his frail state and that he sounds like a poor surgical candidate – especially for emergent neurosurgery.

  9. Christine Boudreau says:

    Emergent bedside subdural drain placement (SEPS) or emergent craniotomy to evacuate subdural hematoma.

  10. akshay says:

    Neurologic exam – GCS, pupils and scan review by nsx to deem whether for op vs. Non op. Management. Sort airway, keep oxygenated, arterial line for gases to keep co2 low-normal. Head of bed 30 degrees, normal glycaemic control. Serial neurologic examinations. WH anticoags. Assess comorbidities and prognosis for ?palliation if appropriate

  11. Vijay lulla says:

    Burr hole craniotomy rule out cardiac arrythmias stop anti platelets LMWH closely monitor in neuro ICU.

  12. SF says:

    Assuming normal liver function/coagulation factors, neurological evacuation of hematoma.

  13. Jorge Anrolinez says:

    As standard of assessment in those cases ABC, probably this event was due hypertension, surgical evacuation and control of the trigger factor

  14. lamiaa says:

    Surgical evacuation

  15. bill martin says:

    Recommend urgent crainiotomy…unless the family requsts terminal supportive care.

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