Clinical note · #60
Critical care
Patient: David Simmons · MRN: 87654213 · Admission: 09/25/2024 · Critical care: 09/26/2024 · Attending: Dr. Lisa Miller
Primary diagnosis: traumatic brain injury with subdural hematoma. Secondary diagnoses: increased intracranial pressure (ICP), hypotension. Critical care time: 145 minutes.
Hospital course
David Simmons, a 27-year-old male, sustained a traumatic brain injury following a motor vehicle accident. He arrived at the hospital unconscious with a Glasgow Coma Scale (GCS) of 4. A CT scan revealed a large subdural hematoma with signs of increased intracranial pressure (ICP). The patient was intubated and hypertonic saline was administered to reduce ICP. An intracranial pressure monitor was placed, and close monitoring of ICP and hemodynamic parameters was performed. The patient experienced episodes of hypotension, requiring vasopressors to maintain cerebral perfusion. Frequent adjustments of sedation, vasopressors, and fluids were necessary to prevent further neurological damage.
Key interventions
- Intracranial pressure (ICP) monitoring
- Hypertonic saline administration
- Vasopressor support for hypotension
Condition: remains critical, with ongoing need for ICP monitoring and vasopressor therapy. Transferred to neurosurgical ICU for further management.