5 Team Management of the Multisystem-Injured Neurosurgical Intensive Care Unit Patient
Abstract
The practice of neurocritical care medicine is vast, comprehensive, and detailed. In order to accomplish the task with the best patient outcome and experience, the neurointensivist needs to both rely on another pair of eyes and perform as part of a team. Because the body is an integration of the neuro, muscular, skeletal, and vascular systems, each working to support the whole, the heath care team should work together, each performing a vital function and relating that function to the entire care of the patient.
Case Presentation
A 23-year-old man is involved in a motorcycle collision against a pole. On primary survey, the patient’s blood pressure is 90/palpable with a heart rate of 120. His pupils are 4 mm symmetrical and sluggish. His only motor response is localization to noxious stimulation. His lung sounds are diminished on the right, and there is a flailed segment on the same side. He has multiple deformities to his extremity.
See end of chapter for Case Management.
5.1 Introduction
The management of a multisystem-injured patient requires the concerted effort of a nonhierarchical though rigorously structured and coordinated prehospital and hospital care team from multiple specialties and is best handled at a designated trauma center that is staffed, equipped, and prepared for such critically injured patients. There are approximately 150,000 trauma deaths annually, three times the number of Vietnam conflict deaths. Of these, approximately 50% are avoidable with the institution of well-organized and meticulously maintained trauma response systems. These systems must include both the field/prehospital teams as well as the in-hospital immediate and longer-term care teams. It is important to understand that there is actually a trimodal distribution of traumarelated death in the postinjury period. The first peak arises due to catastrophic and untreatable injuries that cause immediate posttraumatic death. The second and third peaks, the early posttraumatic mortality period, including secondary respiratory failure and systemic complications, such as overwhelming rhabdomyolysis, and the late posttraumatic mortality period, including hypercoagulable states and cerebral edema, respectively, are relatively preventable causes of death with implementation of efficacious trauma response systems (► Fig. 5.1). The first trauma mortality peak is due to catastrophic injury and untreatable injuries, the second and third peaks in trauma mortality can be reduced by trauma systems that include prehospital, emergency room, operative, and critical care.
Most traumatic injuries are time critical. The “golden hour” beginning from the time of injury to definitive treatment refers to the period during which an interdisciplinary trauma service can have a significant impact on the survival of the patient (► Fig. 5.2). 1 For example, the shorter the time to operative treatment for increased intracranial pressure, or, likewise, intra-abdominal hemorrhage, the better the chances for survival.
5.2 The “Safer Place”
Another important concept in trauma care involves improving the environment of the injured patient. The patient should be removed from the initial hostile, unpredictable, or otherwise inhospitable trauma scene as rapidly as is both safe and feasible and secured in a controlled environment. Typically, this initially involves the ambulance or medical evacuation helicopter followed by the emergency or trauma room and, ultimately, the operating room or intensive care unit. Hostile factors include not only the immediate proximal causes of the injury but environmental and situational factors, such as temperature, noise, and medical resource scarcity, all of which can adversely affect outcome. In point of fact, even the hospital environment can be hostile if the receiving physician is unable to control factors such as room temperature to prevent hypothermia or noise from poor crowd control, especially in the trauma bay, that can detrimentally affect communication and movement, and rapid utilization of studies and definitive treatment (e.g., decompressive craniotomy) (► Table 5.1).
The injury site | Paramedics to the ER | Operating room or ICU |
Unstable environment | More stable environment | Ultimate environmental control |
No monitoring | Monitoring | Advance monitoring |
No treatment | Stabilizing treatment | Definitive treatment |
Abbreviations: ER, emergency room; ICU, intensive care unit. | ||
Taking the patient to a safer place typically involves transportation to an environment such as the intensive care unit or the operating room, where environmental and treatment factors are predictable and controllable.
5.3 Prioritizing Care by the Trauma Team
5.3.1 Primary Assessment and Treatment
The primary assessment or the initial Advanced Trauma Life Support (ATLS) approach to an acutely injured patient requires the prioritized assessment and treatment of vital systems that are required for the support of all vital organs. These systems are defined by the mnemonic ABC (airway, breathing, and circulation). The efficiency of assessment and treatment involves a team of trained professionals: trauma team captain, primary assessor, airway assessor, and trauma nurses. The trauma captain oversees the flow of the patient’s overall care while the primary assessor carries out the majority of the physical examination and treatment. The care team member positioned at the head of the bed manages the airway and is usually an anesthesiologist or another emergency or trauma physician trained in airway management. In concert with the ATLS assessment, trauma nurses perform initial vital signs and placement of monitoring devices. They also start intravenous lines and administer the appropriate medications.
Airway
The loss of airway resulting in inadequate delivery of oxygenated blood to the brain and other vital organs is one of the earliest causes of death in the injured. This systematic approach includes immobilization of the cervical spine because, at this point in the trauma survey, there cannot have been time to fully clear the cervical spine; thus, out of an abundance of caution, it must be assumed that there is traumatic injury to the cervical spine. In the initial trauma survey, there are several indications for placement of an advanced airway to secure the respiratory pathway; some of these include decreased mentation (due to shock or true brain injury), severe maxillofacial injury, aspiration risk (from bleeding or vomiting), obstruction, and inadequacy of respiratory effort (► Fig. 5.3).
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