Gabrielle Giffords and the drama of neuro-intensive care

US Rep. Gabrielle Giffords

Last night it was interesting watching Anderson Cooper and Sanjay Gupta sort of stumble over trying to describe the medical care someone receives after surviving a gunshot wound to the brain. They were, of course, talking about the assassination attempt on Rep. Gabrielle Giffords. They didn't seem very certain what they were talking about (at least, that's how it seemed, but it was closed captioned and I was running on a treadmill) but the AC360 blog video, "What Helped Giffords Survive Brain Shot", is a lot more clear. It's interesting to see the public news media grappling with the strange concepts that are dealt with in neurointensive critical care on a surprisingly frequent basis.  There are also articles trying to answer why Giffords is in a medically induced coma and highlighting the "new" procedure of decompressive craniectomy (I don't think it's that new?), with more or less accuracy.

Of course, the involvement of highly skilled neurointensive care nurses is apparently nil. It's made to sound as if neurosurgeons and doctors are at the bedside watching these patients 24 hours a day. But hey, that's the media.

It is (obviously) possible to survive being shot in the brain, depending on several factors. First, it depends on the round and the trajectory. It doesn't have to be a through-and-through injury, but it probably helps if it's clean through and not explosive.

Secondly, the problem with brain injuries of all types is that even if the initial injury is survivable, the "secondary injury"  is what kills or debilitates patients. I've heard war stories of soldiers being shot in the brain and surviving, awake and talking, for days, and then dying--presumably of swelling or sepsis. The brain swells like anything else after injury, but being in the rigid skull, it has nowhere to go. First the intracranial pressure compresses other brain structures (often the other cerebral hemisphere) which will cause neurological changes. Sooner or later the intracranial pressure can exceed the perfusion pressure of blood reaching the brain--we calculate this as a function of the blood pressure and using an intracranial pressure monitor, a thin catheter placed into the brain--and you have no flow. Swelling may also cause the brain to "herniate" through the hole in the bottom of the skull through which the spinal cord and brainstem connect to the brain, which also compresses those blood vessels, killing the brainstem. Spontaneous breathing stops, your most basic reflexes (coughing, gagging, and blinking) will cease, and there will be no response from the patient to painful stimuli. Death is inevitable unless the blood pressure is supported and they're on a ventilator, but a full brainstem herniation is ultimately unsurvivable. Persistent no flow and brain stem death will lead to a clinical diagnosis of brain death.

CT after craniectomy

So rapid transport to a hospital is critical, followed by rapid assessment, intubation to protect the airway, a head CT scan, and a neurosurgery evaluation. If the patient is a surgical option, they'll open the skull (a craniotomy) to remove clots, and may elect to leave the skull flap off (a craniectomy) to decompress the brain and allow it to swell. The skin is sutured back without the skull and we're on strict precautions (obviously) to leave that part of the head alone. The skull flap is preserved for later reattachment, sometimes in the patient's abdomen, sometimes presumably in some fridge somewhere in the hospital (hopefully labelled and dated appropriately, otherwise the secretary will throw it out--or maybe that's just my lunch).

After surgery the patient typically goes to a specialized neurosurgical or trauma critical care unit staffed by experienced nurses who take over the hour-to-hour care. The patient will be kept intubated and breathing by ventilator. The patient is sedated into the "medically induced coma" the media keeps mentioning, mostly to control pain and agitation. The brain injury, the surgery, the breathing tube, and being restrained to the bed by the wrists (which is done to protect the breathing tube, mostly) all lead to agitation,  which sharply elevates intracranial pressure, so the nurse will be continuously managing those drips as needed. Usually it's propofol because you can shut it off quickly, but the rapid-acting benzo Versed is also used; and a continuous fentanyl or morphine drip for pain.

The nurses will examine the patient hourly for the first day or more, then every two to four hours as the patient stabilizes. Sometimes this will involve turning off the sedation and seeing what the patient does - do they follow commands, open their eyes and track and focus, etc. Otherwise a significant amount of neurological information can be gained even with the patient out - do they react to pain, move all four extremities equally, still have all their reflexes? It's hard to overstate the importance of these exams; the patient can look the same and be totally stable but have a blown pupil or have a diminished reaction to pain in, say, the left arm - these are huge easily overlooked changes that can occur in an hour. We can also determine if we're sedating the patient too much and reduce the drips as needed. If an intracranial monitor or drain is placed it will be monitored fairly continuously. If anything changes, a stat head CT scan is done and the neurosurgeon and critical care physician are notified.  The patient might need more surgeries if there's rebleeding, more swelling, etc.  The nurses will also administer antiseizure meds, meds to reduce swelling, and keep track of the rest of your bodily functions--heart, lungs, etc.

If all goes well, the patient can survive. The patient may need a tracheostomy and feeding tube ("trach and peg"). They'll be taken off sedation and the ventilator if they're able to breathe on their own, but only time will tell if and to what degree there will be any disability, personality changes, or decrease in cognitive function. Some patients are unscathed and others are not.

That's the extent of what I see - the patient is usually transferred to rehab and I don't see them after that. But eventually the skull flap will be placed and stay a night or two in the same intensive care they started out in, which is sometimes nice for us to see.