TBI bolt

[Js315106]

Thoughts on this patient and the treatment plan if you would. 26 yr old male fell through attic. Initial gcs was 13 in ed. He became less responsive and was agitated so subsequently intubated. His CT showed Intracranial bleeding nothing obvious to evacuate. A bolt was placed in ICU at bedside to monitor icp. All pretty straight forward. Here is where I'm confused as to the goals for this patient. This bolt has been in for almost two weeks. The patients icp has been labile and erratic. He has been paralyzed for a time, heavily sedated. Hypeosmolar treatment even 23% saline pushes 10ml at a time but ICP will not stabilize for longer than a few hours at a time. Questions: have you seen bolts in for this long, is there a point at which monitoring icp when it refuses to stabilize becomes fruitless? There really are no surgical options as stated above the bleed is throughout the tissues and not confined to a space commonly evacuated. Any thoughts would be helpful.

[Here.I.Stand, BSN, RN]

He hasn't had a craniectomy yet? With a fall from that height, he's probably swollen. If that's the case he's going to have high ICPs whether there's blood to evacuate or not.

I can't remember how long this pt's devices stayed in, but he had had a bilateral craniectomy-- plus was on vec, heavily sedated, cooled to 37.5° -- and STILL having high ICPs. He was getting 3 or 4 doses of 23% each day, and even had Mannitol... I couldn't help but think," at what point do we start recognize that exercise in futility?

[Js315106]

Of note, though there was bleeding there was nothing in a space that was surgically removable via crani. This bolt stayed in for two weeks and was removed while icps were still labile. Once paralytic and sedation wore off the patient was following some commands. I have never seen a bolt stay in for so long.