RT Book, Section
A1 Backer, Daniel De
A1 Taccone, Fabio Silvio
A2 Lee, Kiwon
SR Print(0)
ID 1143957978
T1 Sepsis and Septic Shock
T2 The NeuroICU Book, 2e
YR 2017
FD 2017
PB McGraw-Hill Education
PP New York, NY
SN 9780071841443
LK neurology.mhmedical.com/content.aspx?aid=1143957978
RD 2024/04/24
AB A  45-year-old  man  is  admitted  to  the  intensive  care  unit  (ICU)  for  head  trauma  related  to  a  fall  on  the  stairs  after  acute  alcohol  intoxication.  He  is  found  by  neighbors  lying  on  the  ground  and  unconscious,  with  no  idea  on  the  delay  since  the  fall.  When  the  ambulance  arrives  on  scene,  the  Glasgow  Coma  Scale  (GCS)  is  8/15,  and  the  man  is  intubated.  On  admission  to  the  emergency  department  (ED)  his  blood  pressure  (BP)  is  150/90  mm  Hg,  heart  rate  86  bpm,  and  temperature  35.9°C.  His  pupils  are  symmetric  (2.5  mm)  and  reflective,  and  there  is  no  obvious  sign  of  lateralization.  The  patient  localizes  to  pain,  does  not  obey  orders,  and  does  not  open  his  eyes.  A  CT  scan  performed  at  ED  admission  discloses  several  petechial  lesions  and  moderate  edema.  The  day  after  admission,  the  patient  becomes  febrile  (temperature  38.6°C)  with  no  obvious  sign  of  infection.  Neurologic  examination  is  deteriorating,  with  the  patient  being  unable  to  localizing  pain  (E1M4V1).  A  repeated  CT  scan  shows  an  increase  in  the  cerebral  contusions  but  no  increase  in  edema  and  no  mass  effect.  Transcranial  Doppler  ultrasound  does  not  show  signs  of  intracranial  hypertension.  The  neurosurgeon  does  not  consider  implantation  of  intracranial  pressure  (ICP)  monitoring  at  this  stage.  During  the  night  the  patient  develops  progressive  hypoxemia  with  a  Pao2/Fio2,  ratio  of  180,  hypotension  (BP  85/40  mm  Hg),  tachycardia,  fever  (temperature  39.5°C),  and  oliguria  (urine  output  0.3  mL/kg/h  at  time  of  assessment).  Clinical  examination  reveals  mottled  skin  mostly  around  the  knees,  no  heat  murmur,  and  a  few  crackles  predominant  at  the  right  lower  lobe.  The  abdominal  examination  is  without  specificities.  An  arterial  blood  gas  reveals  pH  at  7.33,  Paco2  42,  Pao2  72  mm  Hg,  Sao2  95%,  hemoglobin  concentration  8.6  g/dL,  and  lactate  2.9  mmol/L.