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Case Studies

Patient: This seven year old boy suffered a traumatic brain injury resulting in a subdural hematoma with a midline shift.

Monitored Data: A trend display on the CNS Monitor was configured to show heart rate (HR), mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and oxygen saturation (SpO2). These trends were recorded over a 40 minute period.

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Clinical Scenario:

  • No advanced neuromonitoring was employed; only ICP and vital signs were monitored.
  • Despite aggressive medical therapy (including mild hyperventilation, neuromuscular blockade, sedation, and analgesia) the patient continued to have elevated ICP, often in response to stimulation (such as application of EEG electrodes).
  • In the figure, event marks along the timeline indicate significant clinical interventions such as the application of EEG electrodes (1), manual attempts to reduce ICP – position change and therapeutic touch (2), and the administration of hypertonic saline (3). Brief effects of these interventions can be seen on all measurements.
  • Using the CNS Monitor trend display, the physician identified plateau or Lundberg waves that were not visualized on the ICP monitor nor vital signs monitor. Referencing the display, the physician explained the urgency of the situation to the patient’s family members.
  • The patient was taken to surgery for removal of a bone flap and evacuation of an expanding epidural hematoma which had not been visualized on an earlier CT scan.

FIGURE 1: Using the CNS Monitor display, the physician identified Lundberg waves not seen on the ICP or vital signs monitor.

Lundberg waves

Discussion:

The CNS Monitor gave clarity to the patient's condition and assisted in family education and clinical decision making for an emergency hemicraniectomy. Before connecting the CNS Monitor, clinicians had been trying to manage increasing ICP for approximately one hour. During this period of recording with the CNS Monitor, it became apparent that surgery was required.

Without the CNS Monitor, clinicians would likely have continued medical intervention and performed a CT scan. This course of action would have delayed surgery and possibly would have resulted in poorer outcome, longer length of stay, and increased costs. The repeated CT scan would have resulted in further hospital charges and additional radiation exposure for the young patient. On average, a repeated CT scan results in an additional $1,762.40 in hospital charges and exposes the patient to a 21.5 mSv dose of radiation.1 Extended length of stay burdens the patient's family and increases hospital costs. Specifically, the cost for a mechanically ventilated ICU patient is estimated to be $10,794 for the first day and $4,796 for the second day. For any day past the second, the average cost is $3,968 (for a mechanically ventilated patient).2

Reference: Geoff Manley, MD, PhD. University of California, San Francisco. July 10, 2012. Used with permission.

  1. Jones AC, Woldemikael D, Fisher T, Hobbs GR, Prud'homme BJ, Bal GK. Repeated computed tomographic scans in transferred trauma patients: Indications, costs, and radiation exposure. J Trauma Acute Care Surg. 2012 Dec;73(6):1564-9.
  2. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med. 2005 Jun;33(6):1266-71.