Neurocritical Care

A 25-year-old man is admitted after a two-story fall

from a ladder. The initial computed tomography

(CT) scan of his brain reveals a large right tempo-

ral subdural hematoma, an overlying skull fracture,

and a left temporal contusion. His post-resuscitation

Glasgow Coma Scale (GCS) score is E1-M4-V1T.

An intracranial pressure (ICP) monitor is placed

with an opening pressure of 32 mm Hg and a cere-

bral perfusion pressure (CPP) of 53 mm Hg. Serum

laboratory values include sodium (Na) 141 mEq/L,

K 3.6 mEq/L, BUN 8 mg/dL, SCr 1.1 mg/dL, glu-

cose 178 mg/dL, WBC 14.8 × 103 cells/mm3, pH

7.46, and partial pressure of carbon dioxide (Pco2)

34 mm Hg. Which supportive care issue is most rel-

evant to the appropriate treatment of a patient with a

severe traumatic brain injury (TBI)?

because of the lack of gastrointestinal (GI) tol-

erance in severe TBI.

fusion and reduce complications.

ing intravenous fluids to compensate for the

patient’s increased metabolic needs.

within 8 hours of injury to reduce cerebral

edema.

A 69-year-old woman presents to the emergency

department with a 30-minute history of difficulty

with word finding and left upper-extremity weak-

ness. Her NIH Stroke Scale score is 13. A head CT

scan reveals no acute abnormalities. The patient’s

home medications include lisinopril, carvedilol,

warfarin, and atorvastatin. Her medical history

includes hypertension, atrial fibrillation, and tran-

sient ischemic attacks (diagnosed 6 months ago).

Serum laboratory values include Na 145 mEq/L, K

4.0 mEq/L, BUN 18 mg/dL, SCr 1.2 mg/dL, glucose

132 mg/dL, WBC 8.7 × 103 cells/mm3, hematocrit

(Hct) 38.9%, platelet count (Plt) 355,000/mm3, and

international normalized ratio (INR) 1.5. Her vital

signs include blood pressure 167/98 mm Hg, heart

rate 132 beats/minute, oxygen saturation (Sao2) 98%,

and respiratory rate 14 breaths/minute. Which is the

most appropriate next step in this patient’s care?

(10% bolus dose, 90% infusion up to 90 mg

maximum).

systolic blood pressure (SBP) less than 140 mm

Hg, followed by alteplase 0.9 mg/kg intrave-

nously (10% bolus dose, 90% infusion up to 90

mg maximum).

An 18-year-old man is admitted to the intensive care

unit (ICU) after falling from a tree. Initial trauma

screening reveals a C3–C4 fracture and dislocation

with an incomplete spinal cord injury (SCI) at the

corresponding levels (he has some sensory func-

tion bilaterally). The fracture has been reduced, and

he arrives in the ICU 6 hours after injury. Which

is the most appropriate statement related to initiat-

ing high-dose methylprednisolone therapy for this

patient’s SCI?

injury with some sensory function.

perfusion.

adverse effects and questionable benefit.

side the treatment window.

A 27-year-old woman presents with fever, agitation,

hypertension, and muscle rigidity. Her drugs-of-

abuse screen is negative, and serotonin syndrome is a

possible diagnosis. Which home medication is most

likely a causative agent for serotonin syndrome?

A 58-year-old woman with a Hunt and Hess grade

4 SAH resides in your ICU. She is day 6 after her

SAH. Her current medications include 0.9% nor-

mal saline at 100 mL/hour, nimodipine 60 mg by

feeding tube every 4 hours, norepinephrine 0.05

mcg/kg/minute (5 mcg/minute), famotidine 20 mg

intravenously every 12 hours, docusate 250 mg by

tube every 12 hours, and morphine as needed for

headache. Current laboratory values include Na

144 mEq/L, K 4.1 mEq/L, SCr 0.6 mg/dL, serum

osmolality 322 mOsm/L, and Hct 32.3%. Her

blood pressure is 167/99 mm Hg, heart rate 133