Repeat Head CT Research Articles

Dexmedetomidine Controls Agitation and Facilitates Reliable, Serial Neurological Examinations in a Non-Intubated Patient with Traumatic Brain Injury

We report the effective use of dexmedetomidine in the treatment of a patient with a history of chronic alcohol abuse and an acute traumatic brain injury who developed agitation that was unresolved if from traumatic brain injury, or alcohol withdrawal or the combination of both. Treatment with benzodiazepines failed; lorazepam therapy obscured our ability to do reliable neurological testing to follow his brain injury and nearly resulted in intubation of the patient secondary to respiratory suppression. Upon admission to hospital, the patient was first treated with intermittent, prophylactic doses of lorazepam for potential alcohol withdrawal based upon our institution's standard of care. His neurological examinations including a motor score of 6 (obeying commands) on his Glasgow Coma Scale testing, laboratory studies, and repeat CT head imaging remained stable. For lack of published literature in diagnosing symptoms of patients with a history of both alcohol withdrawal and traumatic brain injury, a diagnosis of agitation secondary to presumed alcohol withdrawal was made when the patient developed acute onset of tachycardia, confusion, and extreme anxiety with tremor and attempts to climb out of bed requiring him to be restrained. Additional lorazepam doses were administered following a hospital-approved protocol for titration of benzodiazepine therapy for alcohol withdrawal. The patient's mental status and respiratory function deteriorated with the frequent lorazepam dosing needed to control his agitation. Dexmedetomidine IV infusion at a rate of 0.5 mcg/kg/h was then administered and was titrated ultimately to 1.5 mcg/kg/h. After 8 days of therapy with dexmedetomidine, the patient was transferred from the ICU to a step-down unit with an intact neurological examination and no evidence of alcohol withdrawal. Airway intubation was avoided during the patient's entire hospitalization. This case report highlights the intricate balance between the side effects of benzodiazepine sedation for treatment of agitation and the difficulties of monitoring the neurological status of non-intubated patients with traumatic brain injury. Given the large numbers of alcohol-dependent patients who suffer a traumatic brain injury and subsequently develop agitation and alcohol withdrawal in hospital, dexmedetomidine offers a novel strategy to facilitate sedation without neurological or respiratory depression. As this case report demonstrates, dexmedetomidine is an emerging treatment option for agitation in patients who require reliable, serial neurological testing to monitor the course of their traumatic brain injury.

HEAD INJURY - BASKETBALL

HISTORY A 16-year-old male sustained a head injury during a 3 on 3 basketball tournament. He gives a history of blunt trauma, a fall with the occiput absorbing the brunt of the force with no loss of consciousness. Since that time, he reports headache (posterior) and visual symptoms (peripheral). Denies neck pain, nausea/vomiting, numbness/tingling or mental status changes. After injury, officials halted play and volunteer medical personnel were summoned to render aid. PHYSICAL EXAMINATION On-court examination (ATC). The individual was found to be intact neurologically and cervical pain/tenderness were absent, active motion of the neck was tested. Cervical pain, tenderness and neurological symptons were absent during active cervical motion. The absence of these findings indicated it was safe for the injured individual to ambulate with assistance to the medical tent for further evaluation. Medical tent examination (physician). Vital signs: stable. Head: small abrasion and tenderness involving the occiput. Neck: no bony or soft tissue tenderness, full/pain-free range of motion. Eyes: PERRLA, EOMI, discs clear, central vision intact but peripheral vision altered. Musculoskeletal: no abnormalities, strength 5/5 overall. Neuro: cranial nerves II-XII intact, motor and sensory - no focal deficits. Mental status: oriented X3, memory intact (immediate, recent, remote), test for antegrade memory loss negative, cognitive ability intact. Provocative maneuvers deferred. Serial examinations followed. Due to persistent symptoms (posterior headache and altered peripheral vision), the individual was transferred to the nearest emergency facility for further evaluation. DIFFERENTIAL DIAGNOSIS Concussion, Grade II Skull fracture(s) Intracranial hemorrhage TESTS AND RESULTS Radiographic studies. AP, open mouth and lateral views of the cervical spine were negative. Special studies. CT head without contract revealed midline and left and right paramidline occipital comminuted fractures. FINAL/WORKING DIAGNOSIS Concussion, Grade II with skull fractures. TREATMENT AND OUTCOMES The individual was admitted to neurosurgery service for observation. The following morning, repeat CT head without contrast revealed no changes from previous study. The individual was discharged with scheduled follow-up on an outpatient basis for further evaluation and care.