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Joyce, a 27-year-old right-handed patient, was involved in a motor vehicle accident. Joyce was an unrestrained passenger in a car that swerved off the road and struck a tree. She was ejected from the car and found unconscious by the emergency medical service personnel.  Public Health Problem with Various Potential Causes and Significant Impact on Society Assignment

After being placed on a spinal board and in a Philadelphia collar, Joyce was transported by helicopter to the nearest emergency department trauma center. Joyce was somewhat combative and unresponsive to commands at arrival. Her pupils were reactive bilaterally (left>right). Her respiratory rate was 40 breaths/minute and labored. Subsequently, an endotrachial tube was placed, and mechanical ventilation was started. Additional treatment included placement of a subclavian intravenous line, arterial catheter, and Foley catheter. Initial evaluation of her cervical spine revealed no abnormal findings and the long spine board and Philadelphia collar were removed. Joyce's diagnostic data were as follows:

BP 90/40 mm Hg HR 100 bpm Resp 40 breaths/min Temp 36.7oC (98oF) Pupils Reactive left>right Glasgow Coma Scale score 9

Joyce's initial computed tomography (CT) scan of the head revealed a left temporal cerebral contusion with a midline shift of brain structures. The CT scan also revealed a left temporal parietal subdural hematoma (SDH). After surgical removal of the hematoma, Joyce was transferred to the critical care unit. Intubation and mechanical ventilation were continued. An intracranial pressure monitoring device was placed. The following were her diagnostic data after surgery:

ICP 25 mm Hg BP 130/88 mm Hg HR 100 bpm Resp 12 breaths/min Temp 37.8oC (100oF) pH 7.48 Pco2 40mm Hg Po2 434 mm Hg HCO3- 20.4 mmol/L

Ventilator settings were as follows:

VT 700 ml Rate 12/min Fio2 100%

AS Joyce recovered from the general anesthesia, she opened her eyes to speech, verbalized incomprehensible sounds, and exhibited abnormal general flexion to obtain a Glascow Coma score of 8. Over the next 2 hours, Joyce's body temperature increased to 38oC (101oF). Despite hyperventilation, Joyce's ICP remained elevated. Her serum osmolality was 282 mOsm/L, K+ level was 3.9 mmol/L, and NA+ level was 139 mmol/L. Post-operative orders included the following:

Fluid restriction to maintain patient's osmolality between 305 and 315 mOsm/L

Furosemide 20mg Q6h IV

Mannitol 25 to 50g periodic bolus

Phenytoin 100 mg IV q6h

Joyce's ICP remained elevated for more than 72 hours, then gradually her pressure stabilized. After 2 weeks in the intensive care unit, Joyce was transferred to a neurologic step-down unit and then to a head injury rehabilitation unit.

1. Discuss the leading cause of head trauma and its impact on society.

2. What is the rationale for using the spinal board and Philadelphia collar.

3. Discuss the Glascow Coma score and the significnce of the it in this case.

4. Discuss special considerations with head injury.

5, List and describe the focal injuries associated with traumatic head injury. Include the mechanism of injury and clinical presentation associated with each.

6. List and describe the diffuse injuries associated with traumatic head injury.

7. Discuss the significance of a midline shift.

8. Based on Joyce's arterial blood gas results, what ventilator changes should be anticipated? What is the desirable arterial carbon dioxide pressure range in the presence of increased ICP?