Mr. S. is a 23-year-old man who sustained a traumatic brain injury as an unrestrained driver in a motor vehicle crash. On admission, his blood pressure (BP) was 158/72 mm Hg, heart rate (HR) 46 beats per minute, respiratory rate (RR) 28 breaths per minute, and temperature 96.2o F (35.6o C). His neurological examination reveals that his right pupil is at 6 mm and reacts sluggishly; his left pupil is 4 mm and reacts briskly. He is nonverbal, extends his arms bilaterally to pain, and opens his eyes minimally to pain. He is quickly intubated and placed on mechanical ventilation. A computed tomography (CT) scan is ordered, which reveals a large right subdural hematoma with cingulate herniation from right to left, as well as right-sided uncal herniation.
He is taken to surgery emergently for a craniotomy to remove the subdural hematoma. After surgery, he arrives in the critical care unit with a ventricular catheter to measure intracranial pressure (ICP). His initial ICP is 24 mm Hg, BP 130/67 mm Hg, mean arterial pressure (MAP) 88 mm Hg, HR 54 beats per minute, RR 12 breaths per minute (controlled ventilation), and temperature 96.1o F (35.5o C). His current Glasgow Coma Scale (GCS) score is 3, but the anesthesiologist did not reverse the anesthesia, choosing to allow it to wear off gradually. He has orders for 3% saline at 20 mL/hr intravenously.
Questions
- Based on the information provided, what is Mr. S.’s preoperative GCS? What is the significance of this number, and how would the nurse describe this to his family?
- Anatomically, what is the cause of his pupillary changes?
- Which of his postoperative findings are of concern?
- Why is the 3% saline ordered, and how will the nurse know if it is effective?
