Chest versus head

Todd Fraser on 04-02-2010

So here's the patient - a young man is involved in a motor vehicle accident. He has significant pulmonary contusions and segmental lung collapse, and has a small haemopneumothorax. He is on 80% oxygen, PEEP 10 and to generate tidal volumes of 300mls, he has plateau pressures of 35cmH20. His CO2 is rising as a result. But his head is not normal either - he has diffuse axonal injury, punctate haemorrhages and a GCS of 5 pre-intubation. So what do you do? How do you manage these conflicting priorities?

6 Comments

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lei min wrote 02-28-2010 04:06:48 pm
Dry patient up may help a little bit

veerendra jagarlamudi wrote 03-09-2010 02:44:11 pm
is hfov an option here at all , bear with me if its a blunder though

Todd Fraser wrote 05-18-2010 04:40:22 pm
I've got no experience with HFOV - how effective is it at CO2 removal?

I think Ramon's suggestions are very interesting. If we can be sure that the blood flow to the effected brain tissue is adequate to maintain perfusion, does it really matter what the CO2 is?

But then, thats the problem isn't it. We still have only very crude estimates of the adequacy of blood flow, particularly to the injured regions.

Charlie Corke wrote 02-11-2010 12:51:03 am
I would think that the head has to take priority. I'd feel uncomfortable letting the CO2 rise too much.

What did you do - and how did it end up?

Todd Fraser wrote 02-15-2010 10:09:34 pm
Yes, I agree Charlie - you might make his lungs better and his head will never be the same again.

It makes me wonder though about other ways of tackling this - can you slow his metabolic rate? Eg panadol, beta blockers etc? Or cooling? Or even ECMO to remove the CO2 without killing his lungs?

Ramon Joel Seastres wrote 02-22-2010 04:05:25 pm
I think by inserting jugular bulb oximetry will assist
in regular monitoring and balancing cerebral metab
rate with acceptable reasonable pCO2 level. One
trauma small study reported used Pumpless Extracorporeal Lung a
al Lung assist device (less problems than pump-driven
ECMO) in severe THI with ARDS is promising.
(JTrauma2005)