HARD DECISIONS IN INTENSIVE CARE UNIT

Intensivecareunitkapak

DIFFICULT CASES IN TRAUMA PATIENTS

Alparslan Koç

Erzincan Bi̇ nali̇ Yildirim University, Mengücek Gazi̇ Education and Research Hospital, Department of Anesthesiology and Reanimation, Erzincan, Türkiye

Koç A. Difficult Cases in Trauma Patients. In: Turan S, editor. Hard Decisions in Intensive Care Unit. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.199-211.

ABSTRACT

The care and treatment of trauma patients with neurological deficits in intensive care units (ICUs) present several challenges. Posttraumatic brain and neurological injuries are among the most severe injuries, both in terms of mortality rates and long-term consequences for survivors. Posttraumatic neurological injuries can be defined mainly as head injuries, spinal cord injuries (SCIs), and peripheral nerve injuries (PNIs). Traumatic brain injury (TBI) is one of the deadliest and most disabling diseases in the world and affects people of all ages, including children, working-age individuals, and elderly individuals. Treatment and care in such circumstances are complex and require both medical and ethical considerations. Treating acute brain injuries focuses on identifying, avoiding, or treating subsequent brain damage. Various monitoring systems and treatment approaches are intended to lower intracranial pressure (ICP) and improve cerebral perfusion. Sedation is necessary to facilitate intubation and ventilation but interferes with neurologic examination, requiring careful balance. Clinicians perform neurological wake-up tests (NWTs) to assess brain-injured patients despite the risks of triggering stress responses. Furthermore, systemic hypotension and hypoxia increase secondary brain damage, highlighting the necessity of improving cerebral perfusion and oxygenation. Airway control and mechanical ventilation methods are crucial. Early tracheostomy is associated with improved neurological outcomes, while prone positioning improves outcomes in acute respiratory distress syndrome (ARDS) but poses risks for brain injury patients. Comprehensive assessment of prone positioning and ICP monitoring is crucial. Spinal shock and neurogenic shock, distinct yet concurrent conditions in SCI patients, require careful differentiation for effective management. Surgical decisions, including the timing of decompressive craniectomy and spinal surgeries, remain controversial. Novel pharmacological interventions, such as neurostimulants like amantadine and riluzole, show potential for cognitive recovery and neuroprotection. Tranexamic acid administered in the first hours after trauma reduces the risk of intracranial hemorrhage. Early physiotherapy aids recovery and prevents complications in TBI patients. Furthermore, family satisfaction and decision-making are crucial in ICU care in post-traumatic patients, and excellent communication leads to better outcomes.

Keywords: Traumatic brain injury; Spinal cord injury; Critical care; Neuroprotective agents; Sedation; Shock

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