Intensive Care Management of a Patient with Severe Head Injury

When hemodynamically secure, with protected airways, optimum oxygenation and no need for urgent decompression, the patient is transferred to the ICU, with an ICP monitoring device in place. In the ICU, based on the level of GCS, CT profile and intracranial pressure, the therapy intensity level (TIL) varies. The victim will be subjected to intense conservative management in order to keep the ICP down and assure adequate cerebral perfusion pressure (CPP). Depending on the need for hemodynamic monitoring, a severe head injury patient may need a triple lumen or Swan-Ganz catheter to ensure adequate hydration and intravascular volume. The type of crystalloids selected should be tailored in such a way as to avoid excessive hemod-ilution. We try to keep the hematocrit of the patient at between 30 and 33 in order to maintain blood viscosity within the physiological range [15]. Metabolic depression by propofol and morphine is vital to keep the patient calm and lower the intracranial pressure and hamper cough reflex. We titrate propofol from 10-75 (g/kg/hour, based on the degree of restlessness and the intracranial pressure of the patient. Since propofol has a short half-life, it gives us the opportunity to evaluate the patient's level of consciousness frequently [16]. To ensure adequate CPP, we may need to use pressors to keep the mean arterial pressure (MAP) up (Table 21.8). Flowchart 21.2 is a pathway for management of a patient with possible increased intracranial pressure.

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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.

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