This Spot Check is based on information from drip.vet’s continuing education: Traumatic Brain Injury.

    FRANCIS

    Francis, a 3-year-old neutered male Yorkshire terrier knocked over an end table and multiple hardcover books on the table hit him on the head. His family found him laterally recumbent after hearing the ruckus and immediately transported him to your hospital. Upon presentation and primary survey, you note the following:

    • Lateral recumbency
    • HR 60 bpm
    • T 99.7°F
    • RR 28 rpm
    • BP 172 mmHg
    • Mucous membranes pink/moist
    • Capillary refill time <2 seconds
    • Strong synchronous femoral pulses
    • Blood glucose 289 mg/dL
    • MGCS 9 (LOC 2, brainstem reflexes 3, motor activity 4)

    You provide supplemental flow-by oxygen, and your team places a large bore peripheral intravenous (IV) catheter. You provide passive surface rewarming. You place the cranial half of the body 20° above the caudal half of the body. You recognize bradycardia with concurrent hypertension is consistent with the Cushing’s reflex and intracranial pressure so order mannitol @ 0.5 gm/kg IV over 20-30 minutes. After the mannitol infusion, you reevaluate Francis and note the following:

    • Lateral recumbency
    • HR 118 bpm
    • RR 30 rpm
    • Temperature 99.9°F
    • BP 147 mmHg
    • Mucous membranes pink/moist
    • Capillary refill time <2 seconds
    • Strong synchronous femoral pulses
    • Blood glucose 172 mg/dL
    • MGCS 14 (LOC 5, brainstem reflexes 4, motor activity 5)

    You continue to provide flow-by oxygen. In the absence of hypovolemia and dehydration, you administer a balanced electrolyte solution at 60 mL/kg/day and continue to monitor vital signs and blood pressure serially. You maintain the 20° elevation of the cranial half of the body.

     

    Check Your Knowledge

    Question: 

    Which ONE of the following is the next most appropriate intervention for Francis?

    A. Induce a barbiturate coma.

    B. Induce hypothermia.

    C. Administer methdone @ 0.1 mg/kg IV q6-8 hr.

    D. Perform a decompressive craniotomy.

     

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    ANSWER:

    C: Administer methdone @ 0.1 mg/kg IV q6-8 hr.

    Rationale

    Francis was presented after sustaining traumatic brain injury. Primary survey findings suggested Francis had elevated intracranial pressure for which you appropriately administered a hyperosmotic agent (mannitol), a Tier 1 intervention. You also provided appropriate Tier 0 interventions, including flow-by oxygen, elevation of the cranial half of the body, and serial monitoring to ensure adequate oxygenation, ventilation, and volume status. Vital signs, blood pressure, blood glucose, and MGCS all improved with your initial treatments. Providing adequate analgesia is a component of Tier 1 interventions. Tier 2 and Tier 3 interventions, including inducing a barbiturate coma, inducing hypothermia, and performing decompressive craniotomy, should be considered when a patient doesn’t respond adequately or clinical decompensation is noted.

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