A 27-year-old male presents with a severe head injury (GCS 4 at the scene), sustained in a high-speed motor vehicle collision. His initial CT scan in the emergency department shows a 2x3x2.5cm frontal haemorrhagic contusion and diffuse oedema. He is taken directly to the operating theatre where an external ventricular drain (EVD) is inserted. The patient is settled into the ICU and his secondary survey does not reveal any other significant injuries. The initial ICP is 32 mmHg after the EVD is connected.
a) If the ICP is refractory to your initial management of sedation, paralysis and correct positioning, what further measures will you consider and why?
b) What are the risk factors for post-traumatic seizures in patients with traumatic brain injury?
a) If the ICP is refractory to your initial management of sedation, paralysis and correct
positioning, what further measures will you consider and why?
b) What are the risk factors for post-traumatic seizures in patients with traumatic brain injury?
This question interrogates the candidate's familiarity with the more outré methods of decreasing a person's intracranial pressure.
Lets face it, anybody can sedate, paralyse and position the patient. Those measures are basic.
a)What further measures will you consider and why?
The Brain Trauma Organisation Guidelines for Management Traumatic Brain Injury contain a set of guidelines, which I have mindlessly parroted here.
Ultimately, there is an escalating series of management strategies which are standard for this scenario.
Control ICP by immediate measures:
Exclude new intracranial pathology:
Maintain cerebral oxygen supply:
Decrease cerebral oxygen demand:
Discuss a decompressive craniotomy with the neurosurgeon.
b) The risk factors for post-traumatic seizures
This answer was taken directly from the Brain Trauma Organisation Guidelines for Management Traumatic Brain Injury. Word for word, in fact; copy and paste. See it here.
I will reproduce them here for ease of reference;
I should probably also digress for a moment to discuss the duration of seizure prophylaxis (the Brain Trauma Foundation recommends no more than 1 week). Post-traumatic seizure management is well covered elsewhere.
Chapter 43 (pp. 563) Cerebral protection by Victoria Heaviside and Michelle Hayes, and
Chapter 67 (pp. 765) Severe head injury by John A Myburgh.
Brain Trauma Organisation Guidelines for Management Traumatic Brain Injury is the definitive source.