Traumatic Brain Injuries / Subarachnoid Hemorrhage / Subdural Hematoma / Intraparenchymal hemorrhage

 CNS emergencies

The patient, with a complex medical history, has signs of traumatic brain injury (TBI) and acute subdural hematoma (SDH). Learners will be tasked with prompt and effective management, including assessing the need for coagulation optimization, blood pressure control, recognizing and treating an intracranial pressure (ICP) crisis, and initiating seizure prophylaxis. 

1. Coagulation Optimization: 

1. Review coagulation labs (INR, PTT, fibrinogen, TEG). 

2. Aggressive reversal of therapeutic anticoagulants. 

2. Consider tranexamic acid if <3 hours and moderate/severe TBI. 

3. Blood Pressure Control: 

1. Set initial blood pressure targets based on age. 

2. Initiate norepinephrine infusion if hypotensive. 

3. Resuscitate as needed with blood products or crystalloid. 

4. Recognizing & Treating ICP Crisis: 

1. Identify signs of neuroworsening, anisocoria, or posturing. 

2. Consider empiric hypertonic treatment while awaiting a STAT CT scan. 

5. Seizure Prophylaxis & Diagnosis: 

1. Administer prophylactic levetiracetam. 

2. Consider vEEG for comatose patients with possible seizures. 

6. General Neurocritical Care Practices: 

1. Ensure airway control as needed. 

2. Implement aggressive fever management. 

3. Avoid hyponatremia. 

4. Target normocapnia and maintain a neutral neck position. 

Thromboelastography (TEG): 

R-Time (Reaction Time): 10.5 minutes (Normal Range: 8 - 12 minutes) 

K-Time (Kinetic Time): 4.8 minutes (Normal Range: 2 - 5 minutes) 

α-Angle (Alpha Angle): 52 degrees (Normal Range: 47 - 74 degrees) 

MA (Maximum Amplitude): 64 mm (Normal Range: 55 - 72 mm) 

G (Shear Elastic Modulus): 11 dynes/cm^2 (Normal Range: 9 - 13 dynes/cm^2) 

LY30 (Lysis 30): 2% (Normal Range: 0 - 8%) 

Interpretation: The TEG profile suggests normal clot initiation, propagation, and strength with mild fibrinolysis. 

In the optimal scenario for the presented case involving a 90-year-old male with a history of CHF, CKD, and suicidal ideation, the initiation of a rapid response is marked by the RN alerting the provider to the patient's condition persisting for more than five minutes. The learner promptly undertakes a systematic approach, seeking pertinent information on physical examination, vital signs, and relevant laboratory and imaging findings. Recognizing the severity of the situation, the learner initiates a Stat Neurosurgery Consult to evaluate the potential need for intracranial pressure (ICP) monitoring, external ventricular drain (EVD) placement, or decompressive hemicraniectomy. Collaborating with the neurosurgical attending, the learner engages in a discussion to formulate a comprehensive management plan, including actions such as elevating the head of the bed, administering analgesics, monitoring metabolic parameters, considering mannitol therapy, and initiating antihypertensives as deemed necessary. In parallel, the participant requests an ICU consultation for ongoing critical care. Following a timely response from the consultation, the patient is intubated, and preparations for transfer to the intensive care unit are made, culminating in the conclusion of the case. This scenario underscores the importance of swift and coordinated decision-making in addressing the complexities of traumatic head injury and associated critical care measures. 

Blood pressure goal less than 140 To control use IV labetalol or nicardipine drip avoid hydralazine Cleviprex can be used in brain bleeds as it is faster on and faster offset usually is cheaper however price has been increased over time

Correct coagulopathy with INR greater than 1 point can give vitamin K 10 mg IV x 1 and 3 to 5 units of FFP or PCC or Kcentra

To reverse uremia/antiplatelets can consider DDAVP 0.3 mcg/kg IV

To reverse heparin or low molecular weight heparin continues protamine sulfate

After tPA or tenecteplase check the fibrinogen and give cryoprecipitate

For rivaroxaban or apixaban given the excellent health

Keep sodium 1 45-1 55 keep glucose less than 180

Seizure Prophylaxis with keppra loading dose 20mg/kg as a one time dose

then keppra 500 bid

If seizures or status do antiepileptic dosing

Status epilepticus (off-label use): IV: 1 to 3 g as a single dose administered at a rate of 2 to 5 mg/kg/minute (Ref) or 40 to 60 mg/kg as a single dose infused over 5 to 15 minutes in combination with a parenteral benzodiazepine. Maximum single dose: 4.5 g

40 to 60 mg/kg single dose over 5 to 15 minutes in combination with a parenteral benzodiazepine

Sample Case:

93M from SNF s/p fall with b/l R > L SDH w/effacement+midline shift not on home AC/AP s/p b/l craniotomy w/ R+L subdural drains w/ FFP and platelet administration found to have interval increase / reaccumulation of L SDH+mass effect new L->R midline shift of 1.4cm w/ resolution of R SDH received Bicarb 2 amps s/p Left revision / evacuation / craniectomy of the L w/ JP drain. Currently has 1 right and 2 left JP drains. Per chart review had cochlear implants that are MRI compatible. Patient currently unresponsive GCS 3 with unequal pupils.

- Patient has had CT head stable postsurgical changes, decreased R inferior Frontal SDH, pneumocephalus increased on R decreased on R, improvement in midline shift

- Patient continues to be unresponsive.

- Patient yesterday had status epilepticus treated with 4mg ativan and keppra 3grams with keppra 750 BID

Vital Signs Noted.

Physical Exam

1 R JP, 2 L JP drains, left bone craniectomy GCS 6T comatose

Neuro: Pupils on the left 2mm sluggish, right pupil irregular has cataract, unresponsive,  corneals, has gag, hard of hearing

positive corneals on the left no corneal on right, positive gag reflex

cardiovascular: regular s1 s2 no mrg, no jvd

Pulmonary: clear to auscultation

Extremities: no swelling

Interval Imaging / Results / Events

Echo EF 45% grade 1 diastolic dysfunction

CT head - Interval increased L> R subdural collections w/ effacement w/ r midline shift

s/p b/l craniotomy w/ R/L subdural drains

CT head: increased L SDH w/ mass effect w/ new midline shift, resolution of r SDH

s/p L Craniectomy + drain

fluid is now largely replaced by pneumocephalus. Stable appearance of the ventricular system.

s/p ativan 4mg keppra 3g load, keppra 750 bid for decreased cr clearance

 EEG moderate diffuse slowing, likely status epilepticus improved with keppra load, burst attenuation at times, diffuse cerebral dysfunction

CT head stable postsurgical changes, decreased R inferior Frontal SDH, pneumocephalus increased on R decreased on R, improvement in midline shift

Assessment

93M from SNF s/p fall with b/l R > L SDH w/effacement+midline shift  s/p b/l craniotomy w/ R/L subdural drains w/ FFP and platelet administration found to have interval increase / reaccumulation of L SDH+mass effect new L->R midline shift of 1.4cm w/ resolution of R SDH s/p Left revision / evacuation / craniectomy of the L w/ JP drain. 

Plan

Neuro: 

- tylenol 650mg NG once

- q1 neuro checks

- c/w keppra IV 750mg BID

- neurosurgery following appreciate recs

- Neurology following appreciate recs - continuous EEG

Pulm:

- Ventilated

CV: 

- SBP goal <150

- labetalol 20 mg IV push sbp > 140

Renal: 

- placed foley in

- LR 75

ID:  

- monitor off abx

GI: 

- NPO except medications

- glucerna 1.5 NGTube 60ml/hr

- pantoprazole 40mg IV push daily

- bowel regimen - senna

Endo:

- lantus 14 units

- FS q6hrs with high dose correctional scale

Heme: 

- Daughter and son wanted to talk to family members to assist with completion of Molst / DNR / DNI

Consults: Neurosurgery, General Surgery

Code Status Full Code, ongoing GOC discussions. 

Foreign Bodies:  peripherals, dentures, right cochlear implant, right cataract, NG tube

Complications frequently seen

Diabetes insipidus

SIADH

<250 osms