Hypertonic Saline for Raised Intracranial Pressure

Hypertonic Saline for Raised Intracranial Pressure

A 40 year old male was brought into ED following a high speed road traffic accident. The patient was ejected from the vehicle. The patient was managed according to ATLS guidelines. He suffered extensive injuries including facial fractures, traumatic subarachnoid haemorrhage and multiple intra-cerebral haemorrhages, a flail chest and thoracic and cervical spine injuries. Once stabilised, the patient was transferred to the neurosurgical intensive care unit where an intra-cranial pressure (ICP) monitor was inserted to measure intracranial pressures. His ICP was persistently raised despite optimising respiratory parameters, deep sedation, muscle relaxation and then mannitol. A decision was made to commence an infusion of hypertonic saline 2.7% according to the local protocol. The ICP improved rapidly and stabilised and removed the need to proceed with surgical decompressive craniotomy.

What is the evidence for the use of hypertonic saline in the treatment of acutely raised intracranial pressure?Read More »

Decompressive Laparotomy in Abdominal Compartment Syndrome

Decompressive Laparotomy in Abdominal Compartment Syndrome

A 55 yr old man developed severe necrotizing pancreatitis with multiorgan failure. One week into his illness he had developed multiple intra-abdominal collections and had high intra-abdominal pressures. Initial conservative management failed, percutaneous drainage of his collections failed to reduce the abdominal pressures, and he underwent decompressive laparotomy.

What is the evidence behind the current guidelines for the measurement of intra-abdominal hypertension and the use of decompressive laparotomy in the management of Abdominal Compartment Syndrome?Read More »

Transfusion in Sepsis

Transfusion in Sepsis

A 85 year old man presented with acute bowel obstruction. He had a history of hypertension and diverticulitis disease, but was active for his age. He was not known to have coronary or any other vascular pathology. At laparotomy, a large diverticulitis abscess was identified. When this was manipulated, he developed an SVT with a ventricular rate of 210 bpm which progressed to VT. He received 1 mg adrenaline and 2 minutes CPR in total, with no electrical shocks. At this point perfusion and pressure returned. Surgery was expedited and simplified. He remained intubated and ventilated on ITU post-operatively. ECG demonstrated global t-wave inversion. He required noradrenaline and adrenaline to maintain blood pressure. During the initial 48 hours, his haemoglobin (Hb) fell from 11.9 g/dl to 8.1 g/dl, raising the suggestion of packed red cell (PRC) transfusion.

What is the most appropriate threshold to transfuse packed red cells in critically ill patients?Read More »

Sodium Bicarbonate in Amitriptyline Overdose

Sodium Bicarbonate in Amitriptyline Overdose

A 40 year old man with pre-existing mental health problems presented after an overdose of 6g of amitriptyline. He was deeply unconscious and required invasive ventilation. He was commenced on bicarbonate therapy and hyperventilated to pH 7.5. Around 12 hours after admission he developed tonic-clonic seizures, a broad complex tachycardia and subsequently suffered a cardiac arrest that was refractory to defibrillation, adrenaline and amiodarone. He was given additional 8.4% bicarbonate and further defibrillation attempts and was successfully resuscitated after 90 minutes.

What is the rationale for the use of sodium bicarbonate in the management of amitriptyline overdose?Read More »

Glycaemic Control on the ICU

Glycaemic Control on the ICU

A 76 year old man with no comorbidities was admitted to the intensive care unit following an oesophagectomy. During routine blood sugar monitoring, his blood glucose was found to be just over 10 for two consecutive readings so he was commenced on a variable rate insulin infusion. Six hours later, despite hourly monitoring, he had a blood sugar of 3.6. The insulin infusion was stopped and his blood sugar rose back to normal levels. He suffered no apparent ill effects from his hypoglycaemic episode.

What is the rationale behind current glycaemic control on the intensive care unit?Read More »

Understanding acute kidney injury

Understanding Acute Kidney Injury

A young man was presented to ED with confusion and a profound metabolica acidosis after ingesting around 400ml of ethylene glycol-based anti-freeze. His GCS deteriorated and he required intubation. He was commenced on iv ethanol and commenced on haemodiafiltration. He initially had a polyuric acute kidney injury, but became anuric after 24 hours. His acidosis normalised within 36 hours, and his creatinine peaked at 549. His urine output improved after a week of oligoanuria and his creatinine reached a baseline of around 150.

What are the diagnostic criteria for acute kidney injury?

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ICP Monitoring in Non-Traumatic Intracranial Haemorrhage

ICP Monitoring in Non-Traumatic Intracranial Haemorrhage

A middle aged man had a sudden collapse with no precipitating features. His GCS on presentation was 3, with unequal but reactive pupils and CT brain showed a large subarachnoid bleed with midline shift. Neurosurgical opinion was to observe for clinical improvement, after which an intervention might be indicated. He was sedated on ICU and his MAP maintained above 80mmHg with noradrenaline. Nimodipine was commenced and mannitol was administered. After 24 hours he had a sedation hold and he began to localise and open eyes spontaneously. He was transferred to the neurosurgical unit.

Should all patients with non-traumatic intracranial haemorrhage have intracranial pressure (ICP) monitoring established?Read More »