![]() ![]() The pressure in the cranial vault is measured in millimeters of mercury (mm Hg) and is normally less than 20 mm Hg. Manara A et al, A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries Journal of the Intensive Care SocietyNovember 2016 Vol 17, Issue 4, pp.Intracranial hypertension (IH) is a clinical condition that is associated with an elevation of the pressures within the cranium.Management of Perceived Devastating Brain injury after Hospital admission, consensus statement ficm.ac.uk/sites/default/files/dbi-consensus-statement-2018.pdf.P The differential diagnosis of fixed dilated pupils: a case report and review Critical Care and Resuscitation 2000 Mar 2(1):34-7.Scotter J, Hendrickson S, Marcus HJ, et al Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis Emerg Med J 2015 32:654-659.In the meantime, we should advocate for our patients and provide the best supportive care possible. ![]() However there is chance to give these often young patients a chance at a good outcome, so we should not rush to withdraw treatment. Ultimately it seems this is still a group with a some poor outcomes. We do also know that given more time families are much more amenable to organ donation which could be an unintended consequence of this policy. In order to be able to better prognosticate, in this complicated group of patients. Now in line with the Manara paper they are now advocating a period of observation in a critical care environment for up to 72 hours (where resources allow) with supportive care. Whereas before, there were often early decisions to withdrawal life sustaining treatment, perhaps creating self fulfilling prophesies of mortality, as one could compare to pH or lactate as markers in cardiac arrest. “Any neurological condition that is assessed at the time of hospital admission as an immediate threat to life or incompatible with good functional recovery AND where early limitation or withdrawal of therapy is being considered” In January this year the intensive care society in the UK, together with the Royal College of Emergency Medicine and the neurosurgical society, published a consensus statement taking into account some of the above and actually advocates for devastating brain injury which they define as : In the 6 month period since the change and publication, 12 patients met criteria, unfortunately none survived but four did progress to organ donation. Following admission to the ICU, two made a full recovery to employment and 3 survived with moderate disability to live at home.Īfter having these 5 cases, they changed their hospital protocol to plan to admit all cases for 72 hours of supportive care and observation. Manara et al published a case series from a trauma centre in the UK of five patients over the last 2 years with perceived devastating brain injury in whom withdrawal of care was delayed to facilitate organ donation. ![]() Given trauma often coincides with toxicology if we can satisfy ourselves that their pupils have an intracranial cause, we know historically they can have good outcomes, but what if we treat them more aggressively?
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