This is the first case in a series looking at critical care medicine. Patients under the care of the critical care team may develop delayed complications of their illness or injuries. These cases can help individuals and teams prepare to identify and manage these patients who become newly, and sometimes unexpectedly, unstable.
This case comes from Dr. Dominique Piquette, academic Intensivist at Sunnybrook Hospital in Toronto, Ontario with updates from Dr. Sameer Sharif (Hamilton Health Sciences, Hamilton, Ontario) and Dr. Ailish Valeriano (Emergency Medicine Resident, McMaster University, Hamilton, Ontario)
Why it Matters
Patients with critical brain injuries may decompensate at any time. Close vigilance is required as a decline in mental status may be subtle at time. Complications of brain injuries must be treated quickly as damage can be rapid and irreversible. In addition, these patients are rarely cared for by an individual and require clear and effective team communication to maintain a shared mental model.
Clinical Vignette
EMS has brought a direct transfer to Neurosurgery from surrounding hospital for SAH. The patient had severe headache for 5 days and was initially treated by GP as migraine. Today, she developed new confusion today and was taken to the local emergency department where a CT scan showed “SAH with hydrocephalus”. Patient has a GCS of 14 prior to transfer but her neurologic status declined during transfer – GCS 11 on arrival.
Case Summary
A previously healthy 46-year old woman is transferred from a surrounding hospital with CT-confirmed diagnosis of SAH with hydrocephalus. The patient is transferred direct to Neurosurgery and booked for OR but experiences progressive decreases in her GCS while awaiting surgery. She is admitted to ICU by the junior resident who attempts management and calls for the fellow. When the ICU fellow arrives, the patient’s GCS is 5 and she then becomes hypotensive and desaturates. The ICU team must secure the airway, manage the blood pressure, and coordinate care with Neurosurgery.
EM Sim Cases 