I wouldn't rely on "tamponade" for the control of intracranial haemorrhage. May work fine in some areas of the body, but to achieve tamponade in the cranium requires ICP to approach mean arterial pressure, and that's not a very survivable position to be in!
Hey, don't you have neurosurgeons in Saginaw, or do you ship 'em all to Detroit (following burr holes)?
Adrian
> from: Renee Nilan <[log in to unmask]>
> date: Mon, 23 Jun 2003 23:42:33
> to: [log in to unmask]
> subject: Re: Taxing case 1 third instalment/ coma case.
>
> OK, let me explain my thought process.
>
> Hyperventilation to PCO2 between 25-30 will decrease ICP but peaks at 8
> minutes and is only effective in the acute phase. I don't think it will buy enough
> time for the patient to be transported to a hospital 30 miles away. It may
> even give you a false sense of security as the patient is leaving your facility.
> I don't know how this correlates to a "CO2" but if you mean the partial
> pressure of carbon dioxide, it should not fall below 25 as you are at risk of
> causing profound vasoconstriction and ischemia to both normal and injured areas of
> the brain.
>
> I agree that mannitol should be given, and if improvement in the first few
> minutes then maybe there is no need for burr hole. It will, given it's longer
> duration of action buy the patient her transport time. However given the
> scenario I doubt she will reap enough benefit. In addition, the decreased ICP
> secondary to Mannitol may cause loss of tamponade and allow more bleeding to occur.
>
> I am not suggesting several burr holes or a craniotomy be performed in the
> emergency department. We know where the blood has accumulated. The patient will
> need a craniotomy regardless of whether she receives a burr hole in the ED or
> not, IF she makes it to the neurosurgeon alive, which is our goal.
>
> So, while contacting an ambulance and the neurosurgeon and while ordering the
> mannitol I would also prepare to perform a burr hole on this patient. If she
> did not show rapid improvement after the mannitol I would rather her die
> having attempted a potential lifesaving procedure in my care than have her die
> without one.
>
> Renee
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