Head Injury Patient Hot Case
GENERAL APPROACH
- Isolated TBI or not
- Phase of illness:
- < 48 hours
- day 2-7
- late
- Complications:
- refractory intracranial pressure, VAP, nosocomial infection, ventriculitis
INTRODUCTION
CUBICLE
- long/short stay
- cooling device: refractory ICP
INFUSIONS
- vasopressors: haemodynamic augmentation for CPP
- sedatives
- neuromuscular blockade for management of shivering during cooling
- phenytoin: seizure prophylaxis
- hypertonic saline
- thiopentone infusion: refractory ICP management
VENTILATOR
- mode
- level of support
- level of oxygenation: FiO2, PEEP (high with chest injuries, aspiration, nosocomial pneumonia, ARDS)
MONITOR
- ICP monitoring: pressure, character
- CPP: >60mmHg
- arterial trace: MAP, swing, pulsus paradoxus, pulse pressure
- ETCO2: 30-40mmHg satisfactory, ask to correlate with a recent PaCO2
- temperature: cooling to < 38.5 C commonly performed if ICP uncontrolled
- CVP: number, waveform
EQUIPMENT
- EVD: CSF pressure prior to drainage, colour, frequency and volume
- Codman:
- EEG: burst suppression if thiopentone required
- tracheostomy
- IDC: colour, volume – jugular venous bulb monitoring
QUESTION SPECIFIC EXAMINATION
- neurological -> head: EVD, craniotomy, midline, 30-45 degrees head up, no neck compression, wounds
-> BOS #: CSF, haemotympanum, otorrhoea, rhinorrhoea, racoon eyes, Battle’s sign
-> unconscious
-> conscious
- hands/arms -> head -> chest -> abdo -> legs/feet -> back (secondary survey)
-> general:
-> cardiovascular:
-> respiratory:
-> abdominal:
- asked to see CT and angiography results
- relevant primary or secondary insults
RELEVANT INVESTIGATIONS
- CT head
- CXR
- electrolytes: paired plasma and urinary
- other organ failures (hepatic and renal)
- ABG: gas exchange, metabolic state
OPENING STATEMENT
=
- isolated TBI or not
- phase of illness
- complications
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC