The Case

Jake is a 23 year old builder brought in by ambulance to your ED after being assaulted and falling backwards onto the gutter, striking his head. He was GCS 8 at the scene (E2, V2, M4) with sats of 89% on room air, blood pressure 95/50, heart rate 110, respiratory rate 10.

On arrival to ED, you decide Jake needs to be intubated for airway protection.   You are assisting the ED registrar with the intubation and have been assigned the role of delivering drugs.  What drugs will you use to induce anaesthesia and at what doses?  

[az_accordion_section] [accordion title=”Answer” id=”acc-1″]One option is to use ketamine at 1.5mg/kg and rocuronium at 1.5mg/kg which for Jake would be 120mg ketamine and 120mg rocuronium. Pharmacology of drugs used in TBI management will be discussed later in the module but it is important to maintain good O2 sats and a stable BP throughout induction, with ketamine’s haemodynamic stability an advantage over other agents.[/accordion] [/az_accordion_section]

Jake is intubated and taken for an urgent CT brain.  The CTB report is as follows:

Multifocal intracranial haemorrhages.

8 mm haematoma posteriorly in the right side of the corpus callosum.

Haematoma in the septum pellucidum.

Haematoma and layering blood elements in the right lateral ventricle and right occipital horn, with layering also in the left occipital horn.

Extensive subarachnoid blood in the right sylvian fissure, and to a lesser extent in the left sylvian fissure.

Small foci of subarachnoid in gyri of both parietal lobes superiorly.

Possible punctate haemorrhages in the pons and medulla.

Grey-white matter differentiation is preserved throughout.

[az_toggle_section] [toggle title=”How would Jake’s traumatic brain injury be classified?” id=”tgl-1″]

Several systems have been described for the classification of traumatic brain injury, largely based on the initial Glasgow Coma Scale. TBI is classified as:

Mild GCS 14-15

Moderate GCS 9-13

Severe GCS 3-8

Based on his GCS, Jake would be classified as having a severe TBI. [/toggle] [/az_toggle_section]