Page 496 - ACCCN's Critical Care Nursing

Neurological Alterations and Management 473

Case study
Sam, a 21-year-old male driver was involved in a high-speed motor haemothorax, fractures 1st to 10th right ribs, transverse spinal T7
vehicle accident on the outskirts of a regional town; car versus a to T10 and L 1 to L5. The CT of the abdomen showed extensive
telegraph pole at high speed with two other people. Sam was subcutaneous gas extending from the lumbar spine into the peri-
partially ejected but his head was trapped between the steering toneal cavity and was in communication with the caecum.
wheel and the seat. When the ambulance officers arrived on Following the X-rays, Sam returned to the OT for further explora-
the scene, he was unconscious (GCS 3) and pupils non-reactive. tion of abdomen and insertion of ICP monitor. Intraoperatively he
His breathing was obstructed with stridorous respirations and remained hypotensive despite intravenous titration of triple
decreased air entry to the right lung. He was bleeding profusely therapy inotropes. On return to the ICU, Sam’s ICP was 10. Blood
from his nose, mouth and open head lacerations. Ambulance staff pressure remained labile and cerebral perfusion pressure fluctu-
cleared his airway, fitted a C spine collar, administered oxygen, ated between 50 and 70. Sam had to be paralysed as he began
obtained IV access and transported him to hospital within thirty shivering from attempts to reduce his temperature (39°C) with a
minutes. Of the two other occupants one was deceased and the related rise in his ICP to 25 mmHg. His GCS remained at 3 through-
other had life-threatening injuries that required transportation to out, sedated with midazolam and fentanyl. 3% saline boluses were
hospital.
initiated to reduce elevated ICP (25) in an attempt to improve his
On arrival in the Emergency Department (ED) at 0130h, Sam had a CCP to >60 mmHg.
GCS 5 (Eyes opening 1, Verbal response 1, Movement 3), pupils Days 2 and 3
were midpoint and sluggish (size 2). Rapid sequence induction For the next two days, Sam remained paralysed and sedated. His
intubation was performed due to an obstructing airway. Initial GCS remained at 3. His ICP ranged from 8 to 15. Interventions were
observations were: HR 130, BP 130/60, SpO 2 100% on FiO 2 1.0. Prior- related to a rise in ICP up to 30, but returned to baseline shortly
ity was given to the other injured occupant to go to X-ray for afterwards. CCP was maintained at 60–65 with noradrenaline and
trauma series of N-rays first. The X-ray department at this regional vasopressin. Pupils reacted sequentially to light size 2.
hospital had one CT scanner and was staffed with only one techni-
cian after midnight. Sam continued to be tachycardic (130) and remained febrile (38.8)
despite aggressive attempts to lower his temperature. A DIC
Within the second hour of being in ED, Sam became haemody- picture was developing evident by the drop in platelets and
namically unstable. His HR increased to 150, SBP dropped to 70 and increase in INR. The paralysing medication prescription was ceased.
Hb dropped from 150 to 108 g/L. The second FAST scan revealed GCS remained at 3 (E1, V1(ETT), M1) with IV infusions of fentanyl
fluid in the left internal flank region adjacent to penetration injury and midazolam. Noradrenaline and vasopressin infusion were
to L groin. The decision was made to forgo further trauma series weaned off over the day.
of X-rays and transport Sam to the operating theatre for an emer- Day 4
gency laparotomy. In OT Sam remained unstable. He was tachy- Sam’s sedation was ceased to facilitate a neurological assessment.
cardic with HR 130–150, blood pressure maintained with packed He achieved a GCS of 5 (E1, V1 (ETT), M3). ICP fluctuated between
red cell transfusion (10 units), fresh frozen plasma (4 units), plate- 9 and17 with CPP maintained at 60–65. A repeat CT showed new
lets (1 unit) (only one unit of platelets available at this regional small parafalcine subdural, left temporal bone fracture, diffuse con-
hospital; if more was required it needed to be ordered from inter- tusions in frontal and occipital regions with extensive oedema. He
state) and colloids. Oxygenation was maintained but EtCO 2 ranged was re-sedated with fentanyl and propofol infusions.
from 50–70.
Weeks 1–3
The operating theatre had one team on at this hour of night, and Daily neurological assessment occurred with gradual reductions in
due to the complexity and instability of patient, the EtCO 2 was sedation requirements. Sam began to open his eyes spontaneously
not able to be managed aggressively with resources available at but was increasingly agitated and restless. ICP monitoring was
the time. Surgical repairs were made to perforations in caecum, removed on day 6 and seizure activity was suspected. Phenytoin
colon and liver and the groin wound was explored, cleaned and was prescribed and commenced.
sutured.
Sam had a tracheotomy performed to facilitate weaning from
Vital signs on arrival in ICU mechanical ventilation. The weaning process was delayed due to
Temperature 37.8°C, HR = 155, BP = 90/40 MAP 61, EtCo 2 50, Pupils a further eight visits to OT for removal of necrotic tissue and
size 2 and reacting. Sam remained ventilated (SIMV VC 18 × 450, PS abdominal washouts related to intra-abdominal and right flank
10, PEEP 10, FiO 2 0.95) and sedated with an IV infusion of fentanyl injuries.
and midazolam. Spinal precautions were maintained with hard
collar and neck in neutral position. Noradrenaline, adrenaline and Eventually Sam was discharged to a surgical ward with impending
vasopressin were commenced to support his MAP which remained transfer to a rehabilitation facility interstate. GCS was at 13 (E4,
labile (range 49 to 60 mmHg). V1 4, M 5) at the time of discharge to ward.
Five hours after admission to ICU, Sam was taken to the CT On discharge (16 weeks later)
department to have the full trauma series of X-rays completed. Sam was decannulated and his GCS was 14 (E4, V1 5, M 5). He was
The brain CT showed diffuse oedema and foci of haemorrhage transferred to a rehabilitation facility interstate to continue his
related to the splenium or posterior portion of the corpus callosum rehabilitation. Rehabilitation service at the regional hospital was
and right frontoparietal cortex. Sam’s other injuries included: R not equipped to deliver the amount of rehabilitation services that