Traumatic brain injury.
A 42-year-old man presents to your intensive care unit (ICU) with acute brain trauma. He reportedly fell from a ladder at home while trying to fix the roof. There has been a loss of consciousness immediately after the fall, and he remains in obtunded mental status. In the emergency department (ED), his eyes open to painful stimulation, and he makes incomprehensible sounds and localizes to pain on the left side but is paretic on the right side (Glasgow Coma Scale [GCS] of 9: eye 2, verbal 2, motor 5). Pupils are reactive to light, and other brainstem reflexes are intact. The patient was intubated with an endotracheal tube. Initial vital signs: heart rate, 130 bpm; blood pressure, 160/90 mm Hg; oxygen saturation, 100% on assist control–volume control mechanical ventilation with FIO2 of 0.4; and tidal volume of 480 mL, at a rate of 12 times per minute. Body temperature is 37.5°C. A computed tomographic (CT) image of the brain without contrast is obtained (Figure 4-1).
Noncontrast computed tomography of the brain.
What are the initial steps in the management of this case?
This is a typical case of severe traumatic brain injury (TBI) with bilateral hemorrhagic contusions in the temporal lobes. Its proximity to the bony structures makes it a frequent location in the brain to be contused in trauma. Resuscitation of TBI patients varies widely, however, because of the heterogeneity of the disease itself. The aim of all good early resuscitation efforts is to begin as early as possible, with many efforts beginning in the prehospital setting, with an attention to airway, breathing, and circulation.
Three specific end points have been found to be independent predictors of poor outcome in the prehospital/ED setting: hypothermia, hypoxia, and hypotension.1 Hypothermia is likely a marker of poor resuscitation, and most would agree that core body temperature should be passively supported during the resuscitation phase rather than actively warmed with a device. Aggressive volume resuscitation for hypotension and adequate ventilation are the primary focus of initial resuscitation efforts. Prehospital resuscitation with hypertonic saline in TBI has failed to demonstrate a long-term benefit,2 and in a post-hoc analysis of the Saline versus Albumin Fluid Evaluation trial,3 fluid resuscitation with albumin was associated with higher mortality rates than was resuscitation with saline. Therefore, the administration of isotonic crystalloids is the preferred method by which to volume resuscitate. All TBI patients should be ventilated to a goal of normal partial pressure of carbon dioxide (Pco2) and be given supplemental oxygen to achieve Spo2 greater ...