Hanging and cerebral edema

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VentdependenT

VentdependenT

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Dude hung himself the other day. GCS in the crapper. CT shows effaced ventricles and sulci with posterior cerebral infarct and loss of grey white interface. No neck fractures.

Would YOU guys try HS or mannitol? Why/why not?
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Bostonredsox said:
I would give mannitol and hyperventilate. But I agree with JDH. It probably ain't gonna make a difference.
Click to expand...

If me and hern are being confused, I take that as a compliment :D

Hern's a better CC doc than me

I think everyone in the room will take the sodium up to 155-160 and then have a grim talk with the family. We'll dick around for a day, maybe more, maybe we'll have to prove the brain death, and then hopefully the organ people will think they can use something.
 
Guy was toast for sure. Neurosurg said dont bother. I would have given mannitol. Need to read more on HS as it seems to be en vogue.
 
Where I work neurosurg would have said he is toast as well and not have offered ICP monitoring. He would receive mannitol, and some would suggest therapeutic hypothermia. Realistically the focus of care would be on organ preservation for possible donation when he is declared brain dead.
 
It depends on the neuro exam. Are you able to tell us more about this? Ultimately, the CT is useful, for the uninitiated - the CT is c/w anoxic injury, but hardly definitive for prognostication.

Now, if he is completely unresponsive and is left with only a corneal reflex on the left, for example, then it is time to have a sit down with family. But, if he is posturing, or otherwise doing "something" then I would move ahead aggressively. Regardless, a cEEG is useful because anoxia often results in seizures and this may cloud your exam and be treatable. Also, if he is in myoclonic status then that information is very useful as well.

I prefer HTS, either 3% or 23.4% to mannitol. Reason being, there can be some ICP rebound with mannitol and often I don't want the patient to be diuresed.

Lastly, I would avoid hyperventilation for treatment of elevated ICP unless you plan to do it only breifly (i.e. on the way to the OR for decompression) and the patient is actively herniating. The effect of hyperventilation is quite temporary as the initial vasoconstriction is overcome by cerebral autoregulation resulting in a significant rebound effect. Keep PCO2 normal.

Cheers,
iride
 
Last edited:
Hernandez said:
Does your NS take anoxic pts for crannies?
Click to expand...


No...I didn't mean to imply they would...I intended to comment more generically about hyperventilating patients.

We medically manage our anoxic patients. Honestly, I don't know of any data on decompressive craniectomy for diffuse cerebral edema as seen in anoxic injuries, such as hangings, near-drownings, and cardiac arrest. Such a decompression would have to be bihemispheric decompression...that could be tricky to do, I imagine. Decompression of one side before the other could result in herniation from the nondecompressed side toward the side of decompression unless the surgery was done really early before ICP was too high.

Regardless, as I am sure you would all agree, these are frustrating patients to care for as they seem to do poorly.

iride
 
iridesingltrack said:
It depends on the neuro exam. Are you able to tell us more about this? Ultimately, the CT is useful, for the uninitiated - the CT is c/w anoxic injury, but hardly definitive for prognostication.

Now, if he is completely unresponsive and is left with only a corneal reflex on the left, for example, then it is time to have a sit down with family. But, if he is posturing, or otherwise doing "something" then I would move ahead aggressively. Regardless, a cEEG is useful because anoxia often results in seizures and this may cloud your exam and be treatable. Also, if he is in myoclonic status then that information is very useful as well.

I prefer HTS, either 3% or 23.4% to mannitol. Reason being, there can be some ICP rebound with mannitol and often I don't want the patient to be diuresed.

Lastly, I would avoid hyperventilation for treatment of elevated ICP unless you plan to do it only breifly (i.e. on the way to the OR for decompression) and the patient is actively herniating. The effect of hyperventilation is quite temporary as the initial vasoconstriction is overcome by cerebral autoregulation resulting in a significant rebound effect. Keep PCO2 normal.

Cheers,
iride
Click to expand...

I dont have NS here. at all. So I manntiol/Hyperventilate and call for a fast motherf*&'n helicopter.
 
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