June 2017

64yo M found down

History 
•64yo M was found down by his landlord and taken to the hospital by EMS. On arrival he was intubated and imaging was obtained. 
•PMH is unknown
 
Examination
•T 36.0, HR 100, BP 100/60, O2 sat 100%, intubated
•Neurologically
•Opens eyes to stimulation
•Intubated
•Does not follow commands
•Localizes with the Left upper extremity greater than the right upper extremity
•Withdraws both legs
•Pupils pinpoint and minimally reactive
•Corneal, cough and gag reflexes are present

Initial Imaging Figure 1

Initial Imaging Figure 2

Initial Imaging Figure 3

 
1.What is this patients GCS?
2. The patient has placement of an ICP wire and external ventricular drain. The drain is left open to drain CSF. His ICPs are initially around 15. Over the next two days they begin to increase above 20. What do you do next?
3. The trauma team is concerned about venous thromboembolism (VTE) prophylaxis. The patient has dopplers that are negative for DVT. You recommend
4. Which of the following describes you?
5. I practice in one of the following locations.
6. Comments
  • findings shows decerebrat posture ,apnoea ,so Hgic stroke vs head trauma, brainstem injury also,,bleeding profile & study is needed to exclude bleeding tendency & don't forget to check for evidence of Narcotics as pin point pupils plus apnoea may be due to this & not decerebration as we mentioned earlier 
  • I am a Final Year Resident at Max hospital Delhi, India India.
    I was just concerned. That regarding Question number 2 , should we not consider surgery as also an option. 
  • Spontaneous ICH .. caugulopathathy should be excluded and then amyloid angoipathic vasculitis and then other causes like AVM and aneurysm 

Case Explanation: Explanation of Answers

•1. Correct answer is 8T (E2, V1, M5). GCS is scored by eye opening (1=no eye opening, 2=opening to pain, 3=opening to voice, 4=open spontaneously), verbal score (5=oriented, 4=confused, 3=saying words, 2=moaning, 1=non verbal, t=intubated), motor score (6=following commands, 5=localizing, 4=withdrawing, 3=flexor posturing, 2=extensor posturing, 1=no movement)
•2. The correct answer is mannitol. The TBI guidelines in 2016 give a Level 1 recommendation against steroids for severe TBI. Hyperventilation can be used in an acute setting for increased ICP, but longterm hyperventilation is not recommended in the TBI guidelines (Level IIB). Early (within 48 hours) prophylactic hypothermia is not recommended (Level IIB).
•The correct answer is Heparin SQ BID. Heparin gtt and BID lovenox would result in increased risk of intracranial hemorrhage. The IVC filter is not recommended for DVT prophylaxis. It may be used in the setting to prevent PE in the setting of DVT and severe contraindications for anticoagulation. 

References:

•Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet, 1974.
•Carney et al. Guidelines for the management of severe traumatic brain injury, 4th edition. Neurosurgery, 2016.

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