Traumatic Brain Injury Case Study - Clinical Course
On August 21, a 34 y.o. Hispanic male suffered a closed head injury
after falling 25 feet from a tree. The patient was orally intubated
at the scene and placed on mechanical ventilation with the following
settings: pressure control
20 cm H20, PIP 25, RR 16, PEEP
+ 5, O2 100%. The returning tidal volume was 700-800 ml. Upon arrival
at the ER, patient was paralyzed and unresponsive. The Glascow
coma score was 4. Auscultation revealed rhonchi and crackles bilaterally
with moderate thick yellow secretions. The patient had the following
arterial blood gas (ABG) values: pH 7.31, PaCO2 36, PaO2 126. SaO2 was
98% on 100% O2. Chest X-rays and a CT
scan of the head were performed.
The
chest x-ray revealed a right upper lobe atelectasis and multiple
rib fractures.
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The
CT head scan showed evidence of a brainstem
contusion and blood in the 4th
ventricle.
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Q4 aerosol treatments with 0.5 cc Ventolin/NS were ordered.
Ventilator settings were changed several days later to the following: SIMV 10, tidal volume 700 ml, PEEP +5, O2 40%. The patient exhibited erratic breathing patterns over the next several weeks. Apneic episodes occurred often, and Kussmaul and Cheyne-Stokes respiratory patterns were also seen. Pressure support trials were performed to help wean the patient from the ventilator.
The weaning parameters on September 12th were: minute volume 9.13 L, RR 30, vital capacity 500 ml,NIF -40 cm H20. The respiratory rate was high, tidal volume low, and the minute volume and NIF were acceptable. NIF should be at least -20 cm H2O. Since this patient's episodes of apnea had become more infrequent during his three weeks on the ventilator, he was extubated later that day. Aerosol treatments were continued with occasional suctioning of small-moderate amounts of white secretions. The patient was discharged on October 9th.
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Medications
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Acetaminophen (Tylenol)
 | Usage: an analgesic for fever or pain.
| | Side Effects: CNS: stimulation, drowsiness
| | Contraindications: hypersensitivity
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Albuterol (Ventolin)
| Usage: relaxes smooth muscle by causing bronchodilation action on beta-2 receptors.
| | Side Effects:
 | CNS: tremors, anxiety, headache, dizziness
| | CV: palpitations, tachycardia, hypertension, angina,
hypotension, dysrhythmias |
| | Contraindications: hypersensitivity of sympathomimetics, tachydysrhythmias
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Ceftazidime (Tazidime)
| Usage: inhibits bacterial cell wall synthesis, which renders cells osmotically unstable.
| | Side Effects:
| RESP: dyspnea
| | CNS: headache, dizziness, weakness, fever, chills
| | GU: nephrotoxicity, renal failure |
| | Contraindications: hypersensitivity to cephalosporins
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Dalteparin (Fragmin)
| Usage: prevents deep vein thrombosis in abdominal surgery patients.
| | Side Effects: CNS: intracranial bleeding
| | Contraindications: hypersensitivity to this drug, cerebrovascular hemorrhage,
cerebral aneurysm
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Magnesium salts (MOM)
| Usage: increases osmotic pressure, draws fluid into the colon and neutralizes
HCL.
Used as a laxative.
| | Side Effects:
| CNS: sedation, confusion, flaccidity, paralysis
| | CV: hypotension, heart block, circulatory collapse |
| | Contraindications: hypersensitivity, renal diseases
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Midazolam (Versed)
| Usage: depresses subcortical levels in CNS. Used for sedation.
| | Side Effects:
| RESP: coughing, apnea, bronchospasm, laryngospasm, dyspnea
| | CNS: confusion, headache, anxiety, tremors
| | CV: hypotension, PVCs, tachycardia, bigeminy, nodal rhythm |
| | Contraindications: shock, hypersensitivity to benzodiazepines, coma
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Morphine (Morphitec)
| Usage: depresses pain impulse transmission at the spinal cord level by interacting
with opiod receptors.
| | Side Effects:
| RESP: respiratory depression
| | CNS: dizziness, confusion, headache, sedation, euphoria
| | CV: change in blood pressure,
bradycardia, palpitations |
| | Contraindications: increased intracranial pressure, bronchial asthma, hemorrhage.
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Sucralfate (Carafate)
| Usage: forms a complex that adheres to an ulcer site.
| | Side Effects: CNS: drowsiness, dizziness
| | Contraindications: hypersensitivity |
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