We describe the relations and treatment of Anguila Patient in intensive care unit in Panama, Central America

1. ANGUILA-PANAMA
The Critical Care Connection

2. TRAUMATIC BRAIN INJURY
CASE REPORT #1 TJR
Dr. Guillermo Castillo Abrego
Medical Director
Neuro and Critical Care Corp.
Critical Care/Internal Medicine
Panama

3. ABOUT US
• Neuro & Critical Care (NCC) is based in
Panama-City, Panama’, Neuro and Critical
Care (NCC) is a one stop shop of critical
care expertise.
• Our mission is to supports and provide the
highest quality critical care service to
patients with life-threatening medical,
surgical, neurological condition, promoting
the highest standards of multidisciplinary
care of critically ill patients and support
their families through education, research
and professional development.
• We offer multidisciplinary professional team
of board-certified physicians (intensivists),
specialist critical care nurses, respiratory
therapists, pharmacists, physical, nutritional
and speech therapists, and social workers.
• We excel in pro-active care that reduces
the probability of complications.
• NCC is a key provider to MDabroad
Networks and Management in Panama.
NEURO & CRITICAL CARE GROUP - NCC PANAMA' 303/11/16

5. OBJECTIVES
• My goal is to explain our role in the continuum of
care offered to critical care cases that begin in
Anguilla.
• Present our role in two recent trauma cases with
different pathologies (Gunshot and Traumatic Brain
Injury).
• Offer observations & recommendations for
improving this treatment relationship.
NEURO & CRITICAL CARE GROUP - NCC PANAMA' 503/11/16

6. NEURO & CRITICAL CARE GROUP - NCC PANAMA' 6
Method of
Operation
Ongoing Case
Communications
with all Members
of the Care
Team, MDabroad
Case Manager in
Panama’ and
Daily Briefing of
Family
03/11/16

8. CASE #1
• NAME: TJR
• GENDER: male
• AGE: 26
• ID: 707543706
• DATE: december 20 th

9. HX
• 26 years old young man from Anguilla Islands , who after
having a car accident crashing to a fixed object had a head
trauma with concussion, periorbital edema, nose bleeding
and oral bleeding and progressive lost of consciousness with
short of breathiness. He arrived to the local medical facility
Hospital in Anguilla, he was with respiratory and
cardiovascular instability, tachycardia, tachypnea needing
urgent tracheal intubation and with the help of Dra. Vonetta
George and her team he had quick stabilization. Once
stable and wounds bleedings on control, they prepare an
urgent medical transfer. They activate the ICU air ambulance,
and transferred to San Fernando´s General Hospital, in
Panama that is a level II trauma center.

10. PMH:
• Cardiopathy (NEG)
• Hormon disorders (NEG)
• Pneumopathy (NEG)
• Gastric/bowel disorders (NEG)
• Neuropathy (NEG)
• Blood Diseases (NEG)
• Allergies (NEG)

11. Airway maintenance and
cervical spine protection
Breathing: ventilation and
oxygenation
Circulation and hemorrhage
control
Exposure/environmental control
Disability: Brief Neurologic
examinaition
Primary survey
Resucitation
Secundary survey
Management
Head to toe Examination
History:
MVT (mechanism of ijnjury,
treatment
AMPLE
Advanced Trauma Life
Support algorithm
A
B
C
D
E

12. PHYSICAL EXAM
• BP=120/70 HR=90 RR=14 Sat=100%
• General: mechanical ventilation, well
sedated, with IV fluids, and secured with a
trauma collar and a hard spine board.
• Head Facial edema, periorbital and facial
swelling, and bleeding in the nose.
• Neck no emphysema or abnormal sounds,
no edema,
• Thorax: no ribs fractures, no hematoma, no
deformities or unstable thorax, Normal
heart sounds, lungs with bilateral crackles
• Abdomen: No defense and no
hematoma. No blood in urinary catheter,
no legs deformities.
• Neurologic GC 4/15
• Sedated, reaction to pain, reactive pupils
in the right eye, ocasionally move the leg
• Cranial pair differed
• Motor Force 1/5, Reflex0/4, sensorial no
assessed.

13. ISS = INJURY SEVERITY SCORE
Region
Head / Neck
Face
Chest
Abdomen
Extremity
External
Injury
1. Minor
2. Moderate
3. serious
4. severe
5. critical
6. survivable
ISS
1-8 Minor
9-15 modera
16-24 serious
25-49 Severe
50-74 critical
75 maximum
ISS = A2
+ B2
+ C2

14. GCS=4/15 GOSE=3/8STBI=severe

15. FULL OUTLINE OF UNRESPONSIVENESS

16. TERTIARY SURVEY
• ECG . normal
• CHEST XRAY: Bilateral lungs infiltrates in the bases. Normal
mediastinum, aortic arch normal. Cardiac arcs normal. No
emphysema or ribs fractures.
• CT SCAN HEAD: left Frontal brain contusion, with bilateral
brain edema, bilateral subdural temporal hematomas, eye
orbit fracture, nose fracture, cribose membrane fracture,
zygomatic fracture.
• CT THORAX: bilateral base infiltration, no hemothorax, no
pneumothorax, small contusion.
• CT ABDOMEN: no free air, no macroscopic injuries.

17. DIAGNOSTICS:
• Brain traumatic Injury 800.00 / 801.9
• Brain Edema 348.5
• Refractary Intracraneal Hypertension
• Frontol Parietal Isquemic- Deluxe
Reperfusion Injury
• syncope 780.2
• lung contusion 861.21
• broncho aspiration pneumonia
507 / 770.18
• Zygomatic-orbital fracture 802.8
• Nose septum fracture 802.0
• cribriform fracture
• Hypoglicemia / Hyperglicemia
• Burst suppresion brain activity
• sinusitis 461 / 473

18. Intracranial
pressure
sensor

19. EARLY CHANGES
• DECEMBER 21TH: intracranial sensor, ICP=14
• DECEMBER 23TH: EEG
Also the Neurophysiologist (Evelia Gomez MD,
Neurologist) did an Electroencephalogram
EEG today showed occasional peaks and
burst of abnormal cortical activity . No
status epilepticus.

21. WHAT´S NEXT?
craniectomy

22. http://enlsprotocols.org/

23. December 30th ICP=30 mmHg
and fever

24. INTRACRANIAL PRESSURE TREATMENTS
• Head elevation
• Centered head
• Normocapnia
• Mannitol 20%.
• propofol
• Hypertonic saline.
• Temperature management therapy

25. WHAT´S NEXT?
hypothermia

26. Dr. Sierra the Neuroradiologist “the results that the cerebral blood
flow was compromised and the arteries has perfusion, but they
are narrowed in the right Cerebral Hemisphere, than the left one.
And there was a high risk of complete hemispheric infarction in
the preliminary results.. There is brain edema , which narrowing
the blood flow and is comprimising the penumbra tissue that could
be saved.”

27. Thermomanagement

28. THERMOMODULATION MANAGEMENT
• The body core temperature is decreased to 33 degrees
Celsius to decrease the inflammation and secondary injury in
the brain.
• It has to be very monitorized, and with electrolytes and ABG
control to ensure maximum efficacy.
• The metabolism is decreased and the acute inflammatory
response is decreased.

29. MECHANISM
Salazar-Reyes H, Varon J: Hypoxic tissue damage and the protective effects of therapeutic hypothermia. Crit
Care & Shock 2005;8:28-31
Abate MG, Cadore B, Citerio G: Hypothermia in adult neurocritical care patiients: a very “hot” strategy not to be
hibernated yet. Minerva Anesthesiol 2008;74:425-30
Radicales Libres NT Exitatorios
H T
Reacciones
Enzimáticas Destructivas
Acidosis Intracelular
Integridad de la Membrana
Lipoproteíca

30. MECANISMOS DE LESIÓN
NEUROLÓGICA

31. MECANISMOS DE EDEMA CEREBRAL
DESPUES DE TRAUMA
CRANEOENCEFÁLICO. MARMAROU PHD.

32. JANUARY 11TH
• The intracranial pressure after the hypothermia decrease in
minutes from 30 to 9 and keep in nearly values until the
rewarming process (36 hours).
33 grades 37 grades

33. CEREBRAL ANGIOTOMOGRAPHY: JAN15TH
• Evidence of Deluxe
Reperfusion circulation in Right
frontoparietal, with some
ischemic lesions in parietal
area. With improve of
narrowing of Right ACM artery
in comparison with previous
cerebral angiotomography.
Distal cerebral blood flow of
ACM . Decrease of brain
Edema. No herniation sign.
•

35. JANUARY 25TH
• Endotracheal culture showed Pseudomona aeruginosa
already treated with meropenem. Was assessed by
Infectologist Dr. Ivan Toala.

37. APACHE II
APACHE II =22 APACHE II =7
JANUARY 5TH FEBRUARY 15TH

38. PHYSICAL THERAPY/
RESPIRATORY THERAPY
• The last weeks in january and the first of february tyrone had
been improving his functions. The grapping function, the
swallowing, and trying to stand up were promoted in the
neurorehabilitation.5
5 3

39. RECOMMENDATIONS
• The patient must continue with physical therapy to ensure the
most recovery in the first year.
• The disability score must be assessed and recorded.
• The physical therapy must be directed to neurological therapy
and functional activities. Mainly with the 3 important function:
grasp, language and standing.
• He must continue with thrombosis prophylaxis until he start to
move out of the bed.
• The phonetics has to be practice, trying to name and identify,
and vocalize words.

40. THANK YOU!.

42. CASE #2
• Patient Name: AC
• Date of Birth: April 27, 1992
• Age years old: 23yold
• Hospital : San Fernando Hospital
• Date of admission: December 23th

43. HX
• Mr. A.C. is a 23 years old man who in December 22th received
a gunshot injury through his neck with acute moderate
bleeding and short of breathiness, he was received by the
trauma team in The Princess Alexandria Hospital in Anguila by
Dra. Vonetta George part of the trauma team, who secure
the main airway, and evidenced a visible wound at superior⅓
portion of the medial border of the right sternocleidomastoid
muscle , with evidence or air bubbles and crepitus on
palpation. The surgical team quickly secure the thorax with a
chest tube, It was transferred monitorized and with to Hospital
San Fernando, directly to the ICU unit.

44. PMH:
• Cardiopathy (NEG)
• Hormon disorders (NEG)
• Pneumopathy (NEG)
• Gastric/bowel disorders (NEG)
• Neuropathy (NEG)
• Blood Diseases (NEG)
• Allergies (NEG)

45. PHYSICAL EXAM
• Intubated Sedated. with Benzodiacepine Drip.
• GCS 4/15 NRPupils Not Neurological Deficit. Not
focalization. Patient mobilized 4 extremities.
• ORL: Sialorrea with blood. Neck and Facial
Subcutaneos Enfisema .
• Cardio: Sinusal Rhythm without vasopressor drip.
• Respi: in Mechanical Ventilation Control Assist.
• Chest: With Right Chest Tube with Oscillating
water Column
• Abdomen: Bowels Sounds normal. Without pain .
• Renal: Urinary Catheter Foley with Adequate
urinary output.
• Neurologic: sedated, entubated, flexion to pain,
not decortication, pupilary light response, réflex
normal 2/4 and no pathologic réflex. No
meningeal signs.

46. MEDICAL DIAGNOSIS:
• Neck Gun Shot Wound
• Tracheal Injury T!- T2
• Esophageal Injury
• Mechanical Ventilation
• Massive left lung atelectasia
• Right Neumotórax
• Facial Subcutaneous Enfisema.
• Left Pneumonia

47. Sequential Organ Failure Assessment (SOFA)
APACHE: 16
SOFA: 4

48. ISS = INJURY SEVERITY SCORE
Region
Head / Neck
Face
Chest
Abdomen
Extremity
External
Injury
1. Minor
2. Moderate
3. serious
4. severe
5. critical
6. survivable
ISS
1-8 Minor
9-15 modera
16-24 serious
25-49 Severe
50-74 critical
75 maximum
ISS = A2
+ B2
+ C2

49. MANAGEMENT
• December 24, 2015
• Patient had been taken to Neck Angiotomography with
Contrast: There was evidence of Tracheal injury from C7 to
T2. Probably Esophageal Injury.
• Gastroenterologist made a endoscopy with evidence of
injury 4-5cm below Cricopharyngeal Cartilage, left and
posterior side.
Patient had been taken to operation Room with
Cardiovascular (Dr Miguel Guerra) and General Surgeons
(Dr. Jorge Martin).
• The Tracheal Injury had been repaired and through
transoperative esophagoscopy there was evidence of
erythema but not perforation of the esophagus. Had been
placed a periesophageal Drain. Surgical Gastrostomy and
Tracheal repair.

51. MANAGEMENT
• December 25, 2015.
• Patient sedated intubated on mechanical ventilation.
• 125/60 HR=86 RR14 Sat 98% GCS 3/15
• ORL ok without secretions.
• Cervical dress clean without bleeding spot
• Chest: With chest tube oscillating column, some roncus.
• Gastrostomy. Ok.
• Abd: receiving omeprazole for ulcer prophylaxis. We discuss with the General Surgeon start the
enteral.nutrition through gastrostomy with additional supplement of Vit C for healing Wound.
• Renal: adequate urinary output more 0.5cc/kg/hr
•

52. COMPLICATIONS: MASSIVE ATELECTASIS
• December 27, 2015
• 146/60 fr 24 HR 98 sat 100 GCS 3/15
• Sedated intubated with midazolam and
fentanyl drip.
• ORL: Abundant secretions
• Cardio sounds normal
• Respi: Breathing sound decrease of left
ventilatory sound. No air entrance
• Respiratory Accessory muscles use and
tachypnea.

53. COMPLICATIONS
• Anesthesia (Dr Espinosa and Russell Batista)
and Cardiovascular has been consulted for
massive left atelectasia.
• Multiples active nebulization had been
administered with SBT + atrovent+pulmicort,
mucosolvan and oral n acetylcysteine
• The endotracheal tube had been removed 2
cm.
• And recruitment maneuver (40/40) had been
administered without clinical improve.
• Had been placed a consult to Pneumology
(dr Victor Pinzon) for Bronchoscopy .
• During Bronchoscopy there was evidence of
mucus plug and abundant secretions +
secretions culture had been taken.
•

54. With evidence of mucous plug left distal bronchial.
After bronchoscopy improve of both segmentals bronchioles.

55. JANUARY 5TH:
• the patient is awake, collaborative, conscious, tolerating
nutrition, and with less cough. He has no fever and the neck
drainage was taken out. He is tolerating deambulation and
eating by oral means. Wound healing normal and still with the
gastrostomy. Lungs normal.
• Assessment: the patient will continue Physical Therapy and
Respiratory Therapy in the Ward Room and will continue with
oral nutrition advancement .
• He was transferred to the hospital room

56. RECOMMENDATIONS
• The patient must be seen with his doctor if presents dysarthria
or chronic cough.
• He needs phonoaudiology therapy if there are problems with
breathing.

58. THANK YOU!
www.neuroandcriticalcare.com