ANGUILA-PANAMAThe Critical Care Connection

TRAUMATIC BRAIN INJURYCASE REPORT #1 TJR

Dr. Guillermo Castillo AbregoMedical Director Neuro and Critical Care Corp.Critical Care/Internal MedicinePanama

ABOUT US• Neuro & Critical Care (NCC) is based in

Panama-City, Panama’, Neuro and Critical Care (NCC) is a one stop shop of critical care expertise.

• Our mission is to supports and provide the highest quality critical care service to patients with life-threatening medical, surgical, neurological condition, promoting the highest standards of multidisciplinary care of critically ill patients and support their families through education, research and professional development.

• We offer multidisciplinary professional team of board-certified physicians (intensivists), specialist critical care nurses, respiratory therapists, pharmacists, physical, nutritional and speech therapists, and social workers.

• We excel in pro-active care that reduces the probability of complications.

• NCC is a key provider to MDabroad Networks and Management in Panama.

NEURO & CRITICAL CARE GROUP - NCC PANAMA' 305/03/23

OBJECTIVES• My goal is to explain our role in the continuum of

care offered to critical care cases that begin in Anguilla.

• Present our role in two recent trauma cases with different pathologies (Gunshot and Traumatic Brain Injury).

• Offer observations & recommendations for improving this treatment relationship.

NEURO & CRITICAL CARE GROUP - NCC PANAMA' 505/03/23

NEURO & CRITICAL CARE GROUP - NCC PANAMA' 6

Method of Operation

Ongoing Case Communicatio

ns with all Members of

the Care Team,

MDabroad Case Manager

in Panama’ and Daily Briefing of

Family

05/03/23

CASE #1 • NAME:  TJR• GENDER:  male• AGE:  26• ID:  707543706• DATE: december 20 th

HX• 26 years old young man  from Anguilla Islands , who after

having a  car accident crashing to a fixed object had a head trauma with concussion, periorbital edema, nose bleeding and oral bleeding and progressive lost of consciousness with short of breathiness.   He arrived to the local medical facility Hospital in Anguilla, he was with respiratory and cardiovascular instability, tachycardia, tachypnea needing urgent tracheal intubation and with the help of Dra. Vonetta George and her team he had quick stabilization.   Once stable and wounds bleedings on control, they prepare an urgent medical transfer. They activate the ICU air ambulance, and transferred to San Fernando´s General Hospital, in Panama that is a level II trauma center.

PMH:

• Cardiopathy (NEG)• Hormon disorders (NEG)• Pneumopathy (NEG)• Gastric/bowel disorders (NEG)• Neuropathy (NEG)• Blood Diseases (NEG)• Allergies (NEG)

Airway maintenance and cervical spine protection

Breathing: ventilation and oxygenation

Circulation and hemorrhage control

Exposure/environmental control

Disability: Brief Neurologic examinaition

Primary surveyResucitation

Secundary surveyManagement

Head to toe Examination

History:

MVT (mechanism of ijnjury, treatmentAMPLE

Advanced Trauma Life Support algorithm

A

B

C

D

E

PHYSICAL EXAM• BP=120/70 HR=90 RR=14 Sat=100% • General: mechanical ventilation, well

sedated, with IV fluids, and secured with a trauma collar and a hard spine board.

• Head Facial edema, periorbital and facial swelling, and bleeding in the nose.

• Neck no emphysema or abnormal sounds, no edema,

• Thorax: no ribs fractures, no hematoma, no deformities or unstable thorax, Normal heart sounds, lungs with bilateral crackles

• Abdomen: No defense and no hematoma. No blood in urinary catheter, no legs deformities.

• Neurologic GC 4/15• Sedated, reaction to pain, reactive pupils

in the right eye, ocasionally move the leg

• Cranial pair differed • Motor Force 1/5, Reflex0/4, sensorial no

assessed.

ISS = INJURY SEVERITY SCORERegionHead / NeckFaceChestAbdomenExtremityExternal

Injury1. Minor2. Moderate3. serious4. severe5. critical6. survivable

ISS1-8 Minor9-15 modera16-24 serious25-49 Severe

50-74 critical75 maximum

ISS = A2 + B2 + C2

GCS=4/15 GOSE=3/8STBI=severe

FULL OUTLINE OF UNRESPONSIVENESS

TERTIARY SURVEY• ECG  .  normal• CHEST XRAY: Bilateral lungs infiltrates in the bases.   Normal

mediastinum,  aortic arch normal.   Cardiac arcs normal.   No emphysema or ribs fractures.  

• CT SCAN HEAD:  left Frontal brain contusion, with bilateral brain edema, bilateral subdural temporal hematomas,  eye orbit fracture,  nose fracture,  cribose membrane fracture,  zygomatic fracture.

• CT THORAX:  bilateral base infiltration,  no hemothorax, no pneumothorax,  small contusion.  

• CT ABDOMEN:  no free air,  no macroscopic injuries.•

DIAGNOSTICS:• Brain traumatic Injury 800.00 /

801.9• Brain Edema 348.5• Refractary Intracraneal

Hypertension• Frontol Parietal Isquemic- Deluxe

Reperfusion Injury• syncope 780.2

• lung contusion 861.21• broncho aspiration pneumonia

507 / 770.18• Zygomatic-orbital fracture

802.8• Nose septum fracture 802.0• cribriform fracture• Hypoglicemia / Hyperglicemia • Burst suppresion brain activity• sinusitis 461  / 473

Intracranial pressure sensor

EARLY CHANGES

• DECEMBER 21TH: intracranial sensor, ICP=14

• DECEMBER 23TH: EEGAlso the Neurophysiologist (Evelia Gomez

MD, Neurologist) did an Electroencephalogram EEG   today showed  occasional peaks and burst of abnormal cortical activity .   No status epilepticus.

WHAT´S NEXT?

craniectomy

http://enlsprotocols.org/

December 30th ICP=30 mmHg and fever

INTRACRANIAL PRESSURE TREATMENTS• Head elevation• Centered head• Normocapnia• Mannitol 20%.• propofol• Hypertonic saline.• Temperature management therapy

WHAT´S NEXT?

hypothermia

Dr. Sierra the Neuroradiologist “the results that the cerebral blood flow was compromised and the arteries has perfusion,  but they are narrowed in the right Cerebral Hemisphere,  than the left one.  And there was a high risk of complete hemispheric infarction in the preliminary results..   There is brain edema , which narrowing the blood flow and is comprimising the penumbra tissue that could be saved.”

Thermomanagement

THERMOMODULATION MANAGEMENT• The body core temperature is decreased to 33 degrees

Celsius to decrease the inflammation and secondary injury in the brain.

• It has to be very monitorized, and with electrolytes and ABG control to ensure maximum efficacy.

• The metabolism is decreased and the acute inflammatory response is decreased.

MECHANISM

Salazar-Reyes H, Varon J: Hypoxic tissue damage and the protective effects of therapeutic hypothermia. Crit Care & Shock 2005;8:28-31

Abate MG, Cadore B, Citerio G: Hypothermia in adult neurocritical care patiients: a very “hot” strategy not to behibernated yet. Minerva Anesthesiol 2008;74:425-30

Radicales Libres NT Exitatorios

H T

ReaccionesEnzimáticas Destructivas Acidosis Intracelular

Integridad de la Membrana Lipoproteíca

MECANISMOS DE LESIÓN NEUROLÓGICA

MECANISMOS DE EDEMA CEREBRAL DESPUES DE TRAUMA CRANEOENCEFÁLICO. MARMAROU PHD.

JANUARY 11TH• The intracranial pressure after the hypothermia decrease in

minutes from 30 to 9 and keep in nearly values until the rewarming process (36 hours).

33 grades

37 grades

CEREBRAL ANGIOTOMOGRAPHY: JAN15TH

• Evidence of Deluxe Reperfusion circulation in Right frontoparietal, with some ischemic lesions in parietal area. With improve of narrowing of Right  ACM  artery in comparison with previous cerebral angiotomography. Distal cerebral blood flow of ACM . Decrease of brain Edema. No herniation sign.

•

JANUARY 25TH

• Endotracheal culture showed Pseudomona aeruginosa already treated with meropenem. Was assessed by Infectologist Dr. Ivan Toala.

APACHE II

APACHE II =22

APACHE II =7

JANUARY 5TH

FEBRUARY 15TH

PHYSICAL THERAPY/RESPIRATORY THERAPY• The last weeks in january and the first of february tyrone

had been improving his functions. The grapping function, the swallowing, and trying to stand up were promoted in the neurorehabilitation.5

5 3

RECOMMENDATIONS• The patient must continue with physical therapy to ensure

the most recovery in the first year.• The disability score must be assessed and recorded.• The physical therapy must be directed to neurological

therapy and functional activities. Mainly with the 3 important function: grasp, language and standing.

• He must continue with thrombosis prophylaxis until he start to move out of the bed.

• The phonetics has to be practice, trying to name and identify, and vocalize words.

THANK YOU!.

CASE #2 • Patient Name: AC• Date of Birth: April 27, 1992• Age  years old: 23yold• Hospital : San Fernando Hospital• Date of admission: December 23th

HX• Mr. A.C. is a 23 years old man who in December 22th

received a gunshot injury through his neck with acute moderate bleeding and short of breathiness, he was received by the trauma team in The Princess Alexandria Hospital in Anguila by Dra. Vonetta George part of the trauma team, who secure the main airway, and evidenced a visible wound at ⅓ superior portion of the medial border of the right sternocleidomastoid muscle , with evidence or air bubbles and crepitus on palpation. The surgical team quickly secure the thorax with a chest tube, It was transferred monitorized and with to Hospital San Fernando, directly to the ICU unit.

PMH:

• Cardiopathy (NEG)• Hormon disorders (NEG)• Pneumopathy (NEG)• Gastric/bowel disorders (NEG)• Neuropathy (NEG)• Blood Diseases (NEG)• Allergies (NEG)

PHYSICAL EXAM• Intubated Sedated. with Benzodiacepine Drip.

• GCS 4/15 NRPupils Not Neurological Deficit. Not focalization. Patient mobilized 4 extremities.

• ORL: Sialorrea with blood. Neck and Facial Subcutaneos Enfisema .

• Cardio: Sinusal Rhythm without vasopressor drip.

• Respi: in Mechanical Ventilation Control Assist.

• Chest: With Right Chest Tube with Oscillating water Column

• Abdomen: Bowels Sounds normal. Without pain .

• Renal: Urinary Catheter Foley with Adequate urinary output.

• Neurologic: sedated, entubated, flexion to pain, not decortication, pupilary light response, réflex normal 2/4 and no pathologic réflex. No meningeal signs.

MEDICAL DIAGNOSIS:

• Neck Gun Shot Wound• Tracheal Injury T!- T2• Esophageal Injury• Mechanical Ventilation • Massive left lung atelectasia• Right Neumotórax• Facial Subcutaneous Enfisema. • Left Pneumonia

Sequential Organ Failure Assessment (SOFA)

APACHE: 16SOFA: 4

ISS = INJURY SEVERITY SCORERegionHead / NeckFaceChestAbdomenExtremityExternal

Injury1. Minor2. Moderate3. serious4. severe5. critical6. survivable

ISS1-8 Minor9-15 modera16-24 serious25-49 Severe

50-74 critical75 maximum

ISS = A2 + B2 + C2

MANAGEMENT• December 24, 2015• Patient had been taken to Neck Angiotomography with

Contrast: There was evidence of Tracheal injury from C7 to T2. Probably Esophageal Injury.

• Gastroenterologist made a endoscopy with evidence of injury 4-5cm below Cricopharyngeal Cartilage, left and posterior side.Patient had been taken to operation Room with Cardiovascular (Dr Miguel Guerra) and General Surgeons (Dr. Jorge Martin).

• The Tracheal Injury had been repaired and through transoperative  esophagoscopy there was evidence of erythema but not perforation of the esophagus. Had been placed a periesophageal Drain. Surgical Gastrostomy and Tracheal repair.

MANAGEMENT• December 25, 2015.

• Patient sedated intubated on mechanical ventilation.• 125/60 HR=86 RR14 Sat 98% GCS 3/15• ORL ok without secretions. • Cervical dress clean without bleeding spot• Chest: With chest tube oscillating column, some roncus.• Gastrostomy. Ok. • Abd: receiving omeprazole for ulcer prophylaxis. We discuss with the General Surgeon start the

enteral.nutrition through gastrostomy with additional supplement of Vit C for healing Wound.• Renal: adequate urinary output more 0.5cc/kg/hr

•

COMPLICATIONS: MASSIVE ATELECTASIS• December 27, 2015

• 146/60 fr 24 HR 98 sat 100 GCS 3/15• Sedated intubated with midazolam and

fentanyl drip.• ORL: Abundant secretions• Cardio sounds normal • Respi: Breathing sound decrease of left

ventilatory sound. No air entrance• Respiratory Accessory muscles use and

tachypnea.

COMPLICATIONS• Anesthesia (Dr Espinosa and Russell Batista) and Cardiovascular has been consulted for massive left atelectasia. • Multiples active nebulization had been administered with SBT + atrovent+pulmicort, mucosolvan and oral n acetylcysteine • The endotracheal tube had been removed 2 cm. • And recruitment maneuver (40/40) had been administered without clinical improve. • Had been placed a consult to Pneumology (dr Victor Pinzon) for Bronchoscopy .• During Bronchoscopy there was evidence of mucus plug and abundant secretions + secretions culture had been taken. •

With evidence of mucous plug left distal bronchial.After bronchoscopy improve of both segmentals bronchioles.

JANUARY 5TH: •  the patient is awake, collaborative, conscious, tolerating

nutrition, and with less cough.  He has no fever and the neck drainage was taken out.  He is tolerating deambulation and eating by oral means.  Wound healing normal and still with the gastrostomy.   Lungs normal.     

• Assessment:  the patient will continue Physical Therapy and Respiratory Therapy in the Ward Room and will continue with oral nutrition advancement .

• He was transferred to the hospital room

RECOMMENDATIONS• The patient must be seen with his doctor if presents

dysarthria or chronic cough.• He needs phonoaudiology therapy if there are problems

with breathing.

THANK YOU!www.neuroandcriticalcare.com