It is 2 am on a relatively busy shift on a Saturday night in the ED. EMS arrives with a 27-year-old male involved in a high-speed motor vehicle collision. He was not wearing a seat belt, and he was found ejected from the vehicle. Upon EMS arrival on scene, the paramedics found him unresponsive, with a GCS score of 9 (E2, V3, M4). The patient had been alone in the car, and he did not have identifying information with him. His vital signs included: blood pressure of 110/80 mm Hg, heart rate of 126 beats per minute, shallow respiratory rate of 8 breaths per minute, and oxygen saturation of 96% on room air. The paramedics attempted an oral airway, but it was aborted, because the patient exhibited a gag reflex. Bilateral nasal trumpets were placed, and a nonrebreather facemask with 100% oxygen was administered. He had deformities to his right ankle and left forearm. He smelled of alcohol. The patient was transported on a backboard with a rigid cervical spine collar to maintain immobilization. As you evaluate him on arrival to the ED, his vitals are essentially unchanged; however, you note that his GCS score is now 7 (E2, V2, M3), as he flexes his right arm to painful stimulus. IV access is established, and as you prepare to endotracheally intubate him, you recognize that this patient?s survival and ultimate neurologic outcome may depend on your initial management.
The 27-year-old male was successfully intubated after premedication with fentanyl and RSI with etomidate and succinylcholine and was placed on mechanical ventilation, with the tidal volume calculated for 8 cc/kg per ideal body weight. He was monitored with continuous ETCO2 capnography, and his CO2 target was 40 mm Hg. Sedation and analgesia were administered via continuous infusions of propofol and fentanyl, and he received an initial dose of levetiracetam for seizure prophylaxis. The trauma and neurosurgery teams were activated, and he received a cranial, cervical spine, abdomen, and pelvis CT. His injuries were limited to his head, where he was noted to have diffuse axonal injury, scattered subarachnoid hemorrhage, a frontal intraparenchymal contusion, and a small subdural hematoma. His spine was radiographically cleared of fractures, and the head of the bed was raised to 30?. The neurosurgeon elected to transfer the patient to the neurologic ICU for placement of a ventriculostomy, brain tissue oxygen monitoring, and continuous EEG. The patient ultimately did not require surgical intervention, his ICP was medically managed, and he was ultimately discharged with a tracheostomy and percutaneous enterogastrostomy to a long-term acute care facility after 14 days. After 9 months of intensive physical, occupational, and speech therapy, he was functionally independent and back at work with mild right-leg weakness, short-term memory loss, and occasional word-finding deficits.
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Last Updated on January 26, 2023