The following information relates to a patient being cared for in your ICU with an isolated severe traumatic brain injury. The patient is heavily sedated and unresponsive.
A photograph of the patient bed-space and monitor, as well as the ventilator settings, arterial blood gas analysis, and plasma biochemistry results are provided.
Based on these data, what therapeutic interventions would you perform in this patient?
Give your reasons.
Photographs of bed space and monitor omitted.
...From cheating and looking at the answer, one can establish that the photograph depicts a trauma patient lying flat in bed, with a cervical collar on, an ETT fixed with ties, and an EVD drainage bag hanging well above their head.
The monitor displays the following values:
Ventilator Settings:
Parameter |
Result |
Normal Adult Range |
Barometric pressure |
760 mmHg (100 kPa) |
|
pH |
7.38 |
7.35– 7.45 |
PCO2 |
45 mmHg (10.5 kPa) |
35–45 (4.6 – 6.0) |
PO2 |
100 mmHg (5.0 kPa) |
|
Bicarbonate |
26 mmol/L |
22 –27 |
Sodium* |
150 mmol/L |
134 – 146 |
Potassium |
4.0 mmol/L |
3.4 – 5.0 |
Chloride* |
114 mmol/L |
100 – 110 |
Urea* |
10.1 mmol/L |
3.0 – 8.0 |
Creatinine |
104 µmol/L |
50–120 |
Glucose* |
15 mmol/L |
3.0 – 7.0 |
Measured osmolality* |
330 mOsm/Kg |
280 – 300 |
This question really asks, "how well do you know the Brain Trauma Organisation Guidelines for Management of Traumatic Brain Injury?" This is discussed in detail elsewhere.
It is difficult to make up a specific answer for this without the monitor photograph. From the college answer, one can predict what the picture would have contained.
In any case, whatever the stimulus photograph, the principles are are all the same:
Maintaining cerebral oxygen supply:
Decreasing cerebral oxygen demand:
Controversial measures:
Our beloved Oh's Intensive Care manual has two excellent chapters to dedicate to this topic:
Chapter 43 (pp. 563) Cerebral protection by Victoria Heaviside and Michelle Hayes, and
Chapter 67 (pp. 765) Severe head injury by John A Myburgh.
There are also the Brain Trauma Organisation Guidelines for Management Traumatic Brain Injury, which one might describe as a definitive reference.
It is debatable as to which of these sources is more out of date. At the time of writing, the BTF guidelines have not been updated since 2007. Oh's Manual has undergone a more recent revision, but is not exactly a well-accepted source of guidelines.