CICM SAQ 2015.2 Q6
Question
You are called to review a 55-year-old female following difficult, prolonged surgery for clipping of a left middle cerebral artery aneurysm. She returned to the ICU intubated, ventilated and with an external ventricular drain (EVD) in situ three hours earlier. She now has frank blood in the EVD. Her blood pressure is 180/100 mmHg, and her intracranial pressure has increased to 57 mm Hg. Outline your approach
Answer
Answer and interpretation
Overview
- This is a very urgent situation
- Likely diagnosis is a surgical catastrophe
- Priorities
- Resuscitate
- Will need urgent CT +/- angiogram
- Contact surgical team
- Control ICP and defend CPP
- Prepare for OT
- Contact family once urgent situation settled
Resuscitate
- PaO2 >90 mmHg, O2 sats >95%
- CO2 32–38mmHg
- Check ETT ties
- Check BP for accuracy, probably allow BP to be a bit on the high side initially (SBP 150 – 170) but not excessively. Avoid hypotension. Treat hypotension carefully (probably noradrenaline rather than metaraminol boluses) to prevent large swings in BP
Urgent CT +/- Angiogram
- Get junior to call CT
- Start packing, obtaining equipment, medications
Contact Surgical Team
Control ICP
- Check reading; level, zero, draining
- ETT ties not tight
- Head up 45 degrees
- Mild hyperventilation (CO2 34 – 38 mmHg)
- Sedation
- Thiopentone bolus 2 – 5 mg/kg
- Opiate/benzodiazepine/propofol
- Paralysis
- Lower drain (5 – 10 cm above foramen magnum) and drain CSF
- Consider osmolar therapy
- Mannitol (100 mL 20%)
- Hypertonic saline (dose)
- Target osm 320
- Maintain CPP if able
- Probably target CPP of 50-60
- Prepare for OT
- Check G+H
- Check coags
- Contact anesthestic/OT co-ordinator
- Cease feeds
- Pass rate: 87%
- Highest mark: 6.9
Additional Examiners’ Comments:
- Some candidates failed to recognise this as an emergency situation and treat appropriately in collaboration with the neurosurgeon.
Examination Library
CICM
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC