Assignment Task
Violet is a 48-year-old female who has just been admitted to the ICU following a motor vehicle accident where her car impacted a tree at approximately km/h. On arrival at the emergency department (ED), she was combative and vomiting. Due to her agitated behaviour, the ambulance crew was unable to immobilise her cervical spine (C-spine) and place the patient onto a hardboard.
Her airway was initially managed with simple airway manoeuvres. She was placed in the lateral position and secretions were suctioned. Her Glasgow Coma S (GCS) was 12 (eyes 3; verbal 3; motor 6). Her pupils were reactive bilaterally (2mm). The decision was made to perform a rapid sequence induction in or protect her airway and safely perform investigations. Following intubation with a size 7mm ETT, initial work-up and resuscitation in the emergency department, Violet was transferred to CT and then theatre for surgery.
Below is a summary of Violets injuries and surgical interventions so far:A CT of the head and neck was performed in order to assess for intracranial blood causing mass effect. The scan revealed an extensive fracture running through the right parietal and squamous temporal bone into the central skull base. There was an extensive subdural haematoma overlying the right cerebral convexity with subarachnoid blood. A moderate midline shift of approximately 10 mm was evident. Contrecoup haemorrhagic contusions were located within the left inferior temporal lobe. Right sided uncal herniation in keeping with cerebral oedema and raised ICP was apparent. There was no evidence of fracture-dislocation to the C-spine. Multiple abrasions and contusions were noted to the face and a non-displaced fracture of the zygomat buttress was identified.
A CT intracranial angiogram and a CT of the aortic arch and carotid arteries were performed as deceleration injury to the cerebrovascular arteries required exclusion. The calibre of the right internal carotid artery within the carotid canal and cavernous sinus was slightly reduced and the vessel irregular. The appearances were suspicious of a dissection flap. However, flow was not limited and the intracranial vessels opacified normally. ACT of the chest, abdomen and pelvis was performed to exclude the presence of either solid or hollow organ injury. The CT excluded a haemothorax/pneumothorax and the heart and mediastinal vessels opacified normally. No intra-abdominal injury was identified but multiple thoracic spine fractures with mild-to-moderate wedge compression were evident in T3, T5 and T9. Activate Windows
Violet underwent an emergency decompressive craniectomy, minimal right parietal lobectomy and EVD insertion. The surgical site was prepared, and the trauma flap raised. On inspection, the brain appeared swollen and tight. The dura was incised, and the clot evacuated. Following evacuation of the clot, the brain continued to swell, mandating extension of the craniectomy anteriorly by 2-3 cm. Extension of the craniectomy permitted brain swelling and the reduction of ICP. The wound was closed and an EVD sited over the left frontal lobe. The pressure on insertion was 18 mm Hg.
Violet was transferred directly to the intensive care unit (ICU) for medical management and monitoring. She has a right-sided IJ CVC with 100ml/hr of Hartman’s solution, 4mcg/min Noradrenaline and 80mg/hr of propofol and 8mg/hr of morphine. Over the first hour of admission you note the ICP to be climbing and note these observations on her monitor and ventilator.
Questions
1. Explain the pathophysiology of Violet’s primary and secondary cerebral insult as a result of her traumatic brain injury, include relevant assessment da and presentation history.
2. Discuss the intra-operative insertion of an EVD as an intervention to manage Violet’s raised ICP, justifying your response using the linked pathophysiology and current evidence.
3. Recommend and critique a plan of care for Violet, considering immediate and ongoing interventions and considerations to manage her raised ICP, justifying your response with relevant clinical data and current evidence.
