Traumatic Brain Injury

A 31-year-old un-helmeted biker presented to our trauma center after a motorbike crash. Patient was unresponsive at the scene and got intubated by paramedics for airway protection. His Glasgow Coma Scale (GCS) at the field was 3T (Table 35.1). Upon arrival to the hospital, his GCS was 8T (opened eye to pain and localized to painful stimulation with right arm). Pupils were equal and reactive. Blood pressure (BP) was 137/87 mm of Hg, pulse was 97/min, respiratory rate was 16/min, temperature was 36.7 °C, and oxygen saturation was 100% on volume control ventilation with minimal settings. Past medical and surgical history was unremarkable. Head Computed Tomography scan (CTH) revealed bilateral traumatic subarachnoid hemorrhage (SAH), bilateral extra-axial hematomas, left occipital contusion, evidence of diffuse axonal injury (DAI), as well as comminuted bilateral parietal and occipital bone fractures with underlying pneumocephalus (Fig. 35.1a, b, c, and d). In addition, he had ruptured right tympanic membrane. CT angiography of head and neck was unremarkable. CT chest showed non-displaced fracture of posterior tenth rib, but no other significant body trauma was found. Lab parameters on presentation were within normal limits. The patient was admitted to the neurocritical care unit, where a right-sided intraparenchymal intracranial pressure (ICP) monitor was placed. Initial ICP recording was 32 mmHg. At the time, mean arterial pressure (MAP) was 84 mmHg with cerebral perfusion pressure (CPP) of 52 mmHg (goal CPP 60–70 mmHg). Head of bed was elevated to 45°, and he was transiently hyperventilated with PaCO2 goal of 30–35 mm Hg. After initial propofol bolus of 20 mg, propofol and fentanyl were started. Intravenous mannitol 20% at the dose of 1 g/kg was administered, and 3% hypertonic saline was started at 100 cc/h. Combined acute measures improved ICP to 20 mmHg initially. However, the patient had multiple ICP crises in the first 2 weeks, requiring multiple sedatives including pentobarbital coma, recurrent boluses of hyperosmolar therapy, and paralytics. Cerebral blood flow (CBF) and partial pressure of brain tissue oxygenation (PbtO2) were closely monitored using intraparenchymal devices and optimized as needed with a goal CBF of 20–40 mL/100 g/min and a goal PbtO2 of 25–35 mmHg. Left-sided external ventricular drain (EVD) was also placed. Patient remained intermittently on pressors while requiring heavy sedation for ICP management. Video EEG (vEEG) was placed to evaluate for non-convulsive status epilepticus (NCSE) and was negative for seizures. Daily transcranial doppler was performed to monitor for vasospasm. On day 11, tracheostomy and percutaneous gastrostomy tubes were placed. During the ICU stay, patient had multiple episodes of paroxysmal sympathetic hyperactivity, and ICU course was further complicated by hospital-acquired pneumonia and grade 3 decubitus ulcer. He was finally discharged to rehabilitation facility after 38 days of hospitalization with a Glasgow Outcome Scale of 13 (Table 35.2). At the time of discharge, he was able to tolerate dysphagia diet with thin consistency. Tracheostomy tube was successfully removed on day 45. He continued to receive aggressive physical, occupational, speech, cognitive, and psychological therapy for 2 weeks in the inpatient rehabilitation facility. He was discharged and sent home with his family and continued outpatient therapy. After 4 months of injury, patient had regained full strength with good cognition (GCS 15) and was able to return to work.