A 46-year-old man is hospitalized after a motorcycle collision. The patient was thrown several feet and was found unconscious by the emergency medical team. On arrival at the emergency department, blood pressure is 160/100 mm Hg, pulse is 58/min, and respirations are 10/min and irregular. The patient does not answer questions or open his eyes to voice or touch. He withdraws all extremities to pain but has no purposeful movements. Pupils are symmetric and sluggish. Bilateral breath sounds are normal. There are abrasions on the face and extremities. Endotracheal intubation is performed for airway protection. Imaging of the head and cervical spine shows no intracranial hematomas, fractures, or dislocations, but diffuse cerebral edema is present. Which of the following is the best initial intervention for reducing intracranial pressure in this patient?

Question

A 46-year-old man is hospitalized after a motorcycle collision.  The patient was thrown several feet and was found unconscious by the emergency medical team.  On arrival at the emergency department, blood pressure is 160/100 mm Hg, pulse is 58/min, and respirations are 10/min and irregular.  The patient does not answer questions or open his eyes to voice or touch.  He withdraws all extremities to pain but has no purposeful movements.  Pupils are symmetric and sluggish.  Bilateral breath sounds are normal.  There are abrasions on the face and extremities.  Endotracheal intubation is performed for airway protection.  Imaging of the head and cervical spine shows no intracranial hematomas, fractures, or dislocations, but diffuse cerebral edema is present.  Which of the following is the best initial intervention for reducing intracranial pressure in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d82d_f526_bc81_fb4a89ae9733_MD0003_00 This patient has severe traumatic brain injury (TBI) with clinical findings of elevated intracranial pressure (ICP) (eg, Cushing triad of hypertension, bradycardia, and irregular respirations) and diffuse cerebral edema on imaging. He should receive immediate treatment with hypertonic saline to decrease his ICP and reduce the risk of cerebral herniation. ICP is determined by the total volume of the 3 distinct brain compartments within the fixed volume of the cranium, with initial ICP-lowering measures targeting these 3 compartments: Brain parenchyma (80% of volume): Osmotic therapy decreases the parenchymal volume by creating an osmolar gradient that draws water out of edematous brain tissue. The most used agents are hypertonic saline (administered via intermittent boluses or continuous infusion) and mannitol. Hypertonic saline is preferred by many over mannitol, a diuretic that can cause volume depletion. Cerebral blood volume (10% of volume): Head elevation (increases venous outflow) and sedation (reduces metabolic demand, minimizes sympathetic response) are classically used. Cerebrospinal fluid (CSF): CSF drainage is typically performed via an external ventricular drain. Lumbar puncture is generally avoided because it may cause an acute pressure gradient (ie, high intracranial to low lumbar) that increases the risk for cerebral herniation (Choice C). For patients with elevated ICP refractory to initial reduction measures, decompressive craniectomy may be necessary; craniectomy removes a substantial portion of the skull, increasing cranial volume and allowing expansion of the brain, which rapidly reduces ICP. (Choice A) Glucocorticoid therapy was once used in TBI to decrease vasogenic edema and inflammation that might contribute to increased ICP; however, it has since been found to increase the risk of death in patients with TBI, so routine use is no longer recommended. (Choice D) Nimodipine is a calcium channel blocker that causes cerebral vasodilation. It has been shown to improve outcomes in patients with aneurysmal subarachnoid hemorrhage (exact mechanism unknown). However, it should not be used in this patient with severe TBI because cerebral vasodilation would increase cerebral blood volume and ICP. Educational objective: Osmotic therapy (eg, hypertonic saline, mannitol) is part of the initial treatment of elevated intracranial pressure in patients with traumatic brain injury. It creates an osmolar gradient that draws water out of the edematous brain tissue, thereby reducing parenchymal volume and overall intracranial pressure. References: Hypertonic saline infusion for treating intracranial hypertension after severe traumatic brain injury. (http://www.ncbi.nlm.nih.gov/pubmed/29463291) Management of elevated intracranial pressure: a review. (http://www.ncbi.nlm.nih.gov/pubmed/31773291)

A 46-Year-Old Man Is Hospitalized After a Motorcycle Collision