Critical Care Mailbag – Isolated Head Trauma

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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brendanC -

"If you have ICP issues, propofol and fentanyl

Hemodynamically Compromised Patients

Fentanyl and then,

Ketamine drip or intermittent boluses"

This is copy/paste from EMCRIT 2014. "analgesia first" was the message. I am assuming that the traumatic SDH/SAH who is intubated fits into the discussion. You seemed to have strayed from your long-time message about post-intubation care or did I miss something?

Dean B., M.D. -

Presumably, one would be starting fentanyl/propofol alongside a vasoactive medication in parallel?
This would allow the patient to be both comfortable & achieve a decent cerebral perfusion pressure.
I am curious as to whether Scott starts noradrenaline/norepinephrine peripherally or goes for epinephrine boluses via a peripheral IV?

Scott G. -

What about for the other end of the spectrum? A patient who is very hypertensive? Say systolic above 200. Is the blood pressure goal the same as atraumatic ICH? Or is the only BP requirement to keep the MAP above 80?

Joseph B. -

If the pathophysiology is Takutsubo then push dose EPI or norepinephrine infusion can worsen dynamic LVOT obstruction.

A systematic review by Nazir et al in International Journal of Cardiology (229, 67-70) also suggested an association between EPI and takotsubo. It makes sense to avoid further exogenous catecholamines in a disease precipitated by excess catecholamines.

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