Crisis Center
ICU Issues
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When treating head trauma, the top priorities for the Intensive Care Unit (ICU) medical team are to stabilize the patient and to determine the severity of brain injury.
To evaluate the brain injury, the physician will first check for any increase in intracranial (inside the head) pressure caused by bleeding and swelling in the brain. As soon as possible the person will be rated on the Glasgow coma scale. It measures eye opening, motor and verbal response and establishes a baseline for tracking changes. During the hours or weeks a patient is in ICU, the medical team will be busy establishing the state of all critical body systems. These include monitoring the following:
- Hematoma.
- Pockets of blood, called hematomas are common in traumatic brain injury. They can be seen with CAT scans and MRIs though sometimes it’s necessary to surgically insert a probe into the skull to measure and monitor intracranial pressure (ICT). Small hematomas often are reabsorbed by the brain but if not absorbed, a hematoma may increase intracranial pressure to dangerous levels. Left untreated, the brain—under pressure with nowhere to go, may push down through the Foramen magnum, the large hole at base of brain where the brain becomes the spinal cord. This creates a very serious condition called herniation that may be incompatible with life. One way to relieve pressure on the brain is though a surgical procedure called a craniotomy where a part of the skull is removed to allow the brain to expand.
- Oxygenation.
- The amount of oxygen being supplied to the brain through the blood supply is monitored at all times. If oxygenation is not adequate, the person may suffer further injury to their brain called hypoxia.
- Bladder and bowel issues.
- The patient may need a catheter to drain the bladder temporarily. Bowel evacuation is monitored as well.
- Seizures.
- Approximately 10% of persons with brain injury may have seizure activity within the first month after injury. An EEG may be needed to determine the prognosis and treatment.
- Circulation.
- There are two primary dangers associated with inadequate blood flow. Deep vein thrombosis (DVT). Patients lying stationary in bed lack sufficient muscle movement to stimulate blood flow which makes them vulnerable to blood clots. Movement of the DVT to the heart or lungs is known as a pulmonary embolus and is the number one cause of death in rehabilitation hospitals.
- Decubitus
- Ulcerations also known as bed sores. Patients unable to move themselves are susceptible to developing skin ulcers that can become infected. Long-term problems may require surgery.
- Infections.
- Fever and an elevated white blood cell count red-flag infection. Common causes are bladder and skin infections, hospital acquired infections, pneumonia, and contamination of wounds at time of injury. Cultures determine the type of infection and course of treatment.
- Skeletal trauma.
- Often multiple traumas to the body are caused by the same event that resulted in the brain injury (such as a car accident). The physician will order scans to identify any breaks in the spine and neck immediately but due to the urgent nature of life-threatening problems, breaks in other bones such as the arms, legs are not given priority. Unless obvious, these breaks can be difficult to diagnose when the patient is unable to communicate. However, if the person remains in ICU for more than a couple of days, doctors will need to be proactive. Too much delay in treatment may affect long-term function. Muscles should be exercised three to four times a day to prevent atrophy or muscle loss. This needs to be done in ICU.
- Nutrition.
- Adequate nutrition is necessary for healing and this is addressed in ICU via IV fluids or special tubes.
By definition, a person in ICU has at least one potentially life-threatening condition. This can be a frightening time for emotionally distraught family members who are trying to process new information, terms, and procedures while being asked to make critical decisions for their loved one. But the more a family learns about the medical environment, the more empowered they become to support their loved. For further information about the role of family members in the ICU experience, go to ICU and Families.
Shepherd Center, a Center of Excellence Facility
Dr. Donald Leslie is Associate Medical Director of Shepherd Center and an elected member of the Center’s Board of Directors. He is Medical Director of brain injury services at Shepherd, which includes inpatient and post-acute brain injury rehabilitation programs and recently became head of their new geriatric brain injury unit. He is Co-Medical Director of the Georgia Model Brain Injury System. Dr. Leslie has spoken nationally and internationally on spasticity management, and has been involved in intrathecal baclofen research and therapy for the past ten years. Most recently, Dr. Leslie received certification in acupuncture at UCLA in Santa Monica, California.