1. The patient presented with a head injury resulting in subdural hematomas and increased intracranial pressure requiring neurosurgery. 2. An additional concern was rapid atrial fibrillation which can occur in up to 6% of severe head injury patients due to catecholamine release and is associated with worse outcomes. 3. Treatment involved active cooling, hypertonic saline, and beta blockers to moderate the adrenergic response while balancing effects on cerebral blood flow.

1. Medical Concerns
Primary Survey Secondary Survey
A  Head /Neck Occipital heamtoma
B  C3/4 tenderness
C HR 125-160 rapid AF  Epistaxis
BP 150/85 Chest 
Abdo 
warm well perfused Pelvis  FAST neg
D GCS 13 Back flank abrasion
E abrasion on back T12/L1 tender
36.6 no step deformity
UL/LL 
Plan....
RSI combative/head injury
CT BRAIN/c spine/CXRAY
Bloods including ETOH
Antiemetic/analgesia
Arterial line /IDC

2. Major Issues
1. HEAD INJURY
Undisplaced # vertex skull
Bilateral subdural haematomas
Extensive Bilateral SAH
Increasing ICP requiring
Neurosurgical intervention
2. Inconsistency in the mechanisms/
history
3. Rapid AF

3. Rapid AF
(Presumed)
Otherwise healthy 27yo male 140-180bpm
No structural heart
disease, congenital, valvular
pathologies, cardiomegaly
Consider....
Shock (tachycardia)
-heamorragic/hypovolemic
-myocardail ischemia/infarction
Electrolyte imbalances
Infection
Pain
ETOH
Chest trauma
Head Injuries
TFTs (normal)

4. Arrhythmias in Head Injuries
(Neurogenic cardiac dysfunction)
• Uncommon occurrence (6% SICU)
• AF, Flutter, PSVT, PVC, PAC, Prolonged QT
• Mostly associated with ICH, SAH
• BAD prognostic sign (x 2 higher mortality rate)
Why?
• Catecholamine storm lasting up to 10 days
? Protective mechanism to maintain CPP in face of a
rising ICP (CPP =MAP-ICP)
Also other causes...
• Hypoxia, hypercapnia
• Pulmonary Artery catheter placement, CVC
• NDI – loss of electrolytes (low Mg, Ca, K)
Most occurs within 7days of insult
Majority of these in first 48hrs.

5. What do we do?
B Blockers....
Treat the cause!
any AF - Head injury! • There is discussion regarding the
Surgery! use of b-blockers in this situation
Most patients who die will because of their brain injury
during the peri operative period.
<24hrs a decision should be made regarding anticoagulation vs
obvious bleeding risks
• Small number of studies have
Very rarely lead to fatal arrhythmias shown a protective effect on
mortality and reduces cardiac
Non surgical treatment ie mild SDH, contusions.. complications during ICU stay.
- Telemetry/ ECG and trops
• ? this is due to moderate the
- Treat if pt heamodynatically unstable physiological adenrenergic strain
- TTE caused by catecholamine release.
- Replace electrolytes
• No consensus on this am must be
balanced with the reduction this
could cause in cerebral blood flow
• Gregory 2011/Hadjizacharia 2007

6. Mr O
Back to the patient...
Westmead ICU (27days) • TFTs normal
• EVD inserted and elevated ICP • TTE normal
• Active cooling • Almost back to baseline
• Hypertonic saline level of function
• Digoxin and Mg admin for AF • Is not likely to require long
• VAP term Rehab (OHS)
• Developed an occlusive R IJ, SC
Auxiliary and brachial vein
Thrombus

7. Real story
Pt was “bonnet surfing”
“Bonnet surfing”

8. References
Trappe HJ. Treating critical supraventricular and ventricular arrhythmias. J Emerg Trauma Shock [serial online] 2010 [cited 2013 Apr
8];3:143-52. Available from: http://www.onlinejets.org/text.asp?2010/3/2/143/62114
Grunsfeld A, Fletcher JJ, Nathan BR Curr Neurol Neurosci Rep.
Cardiopulmonary complications of brain injury. 2005 Nov;5(6):488-93.
Incidence, Risk Factors, and Outcomes for Atrial Arrhythmias in Trauma Patients
Hadjizacharia, Pantelis;O'Keeffe, Terence;Brown, Carlos V R, MD;Inaba, Kenji;Salim, Ali;Chan, Lin...
The American Surgeon; May 2011; 77, 5; ProQuest Central
Gregory and Smith 2011 “Cardiovascular complications of brain injury” Continuing Education in Anaesthesia, Critical Care & Pain
Clemo HF, Wood MA, Gilligan DM, Ellenbogen KA. Intravenous amiodarone for acute heart rate control in the critically ill patients with
atrial tachyarrhythmias. Am J Cardiol 1998;81:594-8
Overview of Adult Traumatic Brain Injuries. Copyright 2011 Orlando Health, Education & Development
Macha Bourdages, MD, MSc; Jean-Luc Bigras, MD; Catherine A. Farrell, MD; James S. Hutchison, MD;
Jacques Lacroix, MD; 2010 Cardiac arrhythmias associated with severe traumatic brain injury
and hypothermia therapy* Pediatr Crit Care Med Vol. 11, No. 3
Xavier Wittebole, et al 2005. Electrocardiographic changes after head trauma. Journal of Electrocardiology 38; 77–81
The Brain Trauma Foundation https://www.braintrauma.org/