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