Chapter 4.

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INTENSIVE CARE MONITORING AND NURSING CARE

Note:
Procedure standards for Intensive Care Unit (ICU) personnel treating a traumatic brain injury (TBI) casualty are described.

Contents:
4.1.: General monitoring
4.2.: Neurological monitoring
4.3.: Neuroradiological monitoring
4.4.: Nursing care

STANDARD 4.1.: GENERAL MONITORING Hvezdicka.GIF (147 bytes)

For intensive care of patients with traumatic brain injury and GCS between 3 and 8, the following parameters should be monitored:

1. cardiovascular parameters
1.1. pulse rate continuously
1.2. blood pressure continously (better invasively)
1.3. ECG continuously
1.4. central venous pressure continuously

2. biochemical parameters
2.1. SaO2 and PetCO2 continuously
2.2. blood gases: PaO2, PaCO2, ABR daily and as indicated
2.3. serum: sodium, potassium, glucose, hematocrit, hemoglobin, albumin, osmolality, and oncotic pressure daily
2.4. urine: diuresis per hour, urinary output (sodium, potassium, glucose, and urea) daily, urinalysis 2x weekly
2.5. gastric output daily

3. arteficial ventilation parameters
3.1. respiratory rate continuously
3.2. respiratory volume continuously
3.3. inspiration pressure continuously
3.4. PEEP continuously

4. general care parameters
4.1. body temperature q 1-3 hours
4.2. fluid balance and nutrition daily
4.3. microbiological tests of URT and urine 2x weekly

For intensive care of patients with traumatic brain injury and GCS between 9 and 12, the following parameters should be monitored:

1. cardiovascular parameters
1.1. pulse rate continuously
1.2. blood pressure continuously
1.3. ECG continuously

2. biochemical parameters
2.1. SaO2 continuously
2.2. serum: sodium, potassium, glucose, hematocrit, hemoglobin daily
2.3. urine: diuresis per hour, microbiological tests in catetherized patients weekly, and urinalysis 2x weekly

3. ventilation parameters
3.1. respiratory rate q 1 hour

4. general care parameters
4.1. body temperature q 3 hours
4.2 fluid balance and nutrition daily

Patients with traumatic brain injury and GCS 13 or more do not require intensive care. Close observation in a standard ward should include:

1. cardiovascular parameters
1.1. pulse rate q 1-6 hours
1.2. blood pressure q 1-6 hours

2. biochemical parameters
2.1. serum: sodium, potassium, glucose, hematocrit, hemoglobin on admission and when required
2.2. urine: urinalysis on admission and when required

3. ventilation parameters
3.1. respiratory rate q 1-6 hours

4. general care parameters
4.1. body temperature on admission and when required

Commentary:
4.1.2. General monitoring in intesive care

STANDARD 4.2.: NEUROLOGICAL MONITORING Hvezdicka.GIF (147 bytes)

Neurological monitoring for intensive care of patients with traumatic brain injury and GCS between 3 and 8 should include:
1. clinical neurological state daily and when required
2. Glasgow Coma Scale (GCS) hourly (during first hours of injury more frequently)
3. intracranial pressure (ICP) continuously
4. jugular bulb venous blood oxygenation (SjvO2) during hyperventilation daily
5. neurophysiological monitoring (EEG and/or SEEP) when indicated

Neurological monitoring for intensive care of patients with traumatic brain injury and GCS between 9 and 12 should include:
1. clinical neurological state daily and when required
2. Glasgow Coma Scale (GCS) hourly (during first hours of injury more frequently)

Patients with traumatic brain injury and GCS 13 or more do not require intensive care. Close observation in a standard ward should include:
1. clinical neurological state on admission and as indicated
2. Glasgow Coma Scale (GCS) hourly (during first hours of injury more frequently)

STANDARD 4.3.: NEURORADIOLOGICAL MONITORING Hvezdicka.GIF (147 bytes)

The first CT scan is taken on admission. The follow-up CT scan is performed in 24 hours, or earlier if a change in the clinical status or monitored parameters (particularly ICP) of the patient is observed.

Magnetic resonance imaging (MRI) is indicated in brain stem lesions, small haematomas, and tiny contusions.

Transcranial Doppler sonography (TCD) should be a standard monitoring method in trauma centres.

Commentary:
4.3.1. Posttraumatic cerebral turgescence

STANDARD 4.4.: NURSING CARE Hvezdicka.GIF (147 bytes)

It is critical to avoid any improper movements of the head, particularly tilting back and rotation, during nursing care. Patients lie on heat-isolated beds naked and uncovered. It is preferred to maintain mild hypothermia. Rehabilitation is induced early. The European Questionnaire for brain injuries is used uniformally.

Coordinated by Tomas BERAN, M.D.

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Last updated: 1999-09-06