Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Sedatives and chemical paralytics

Varies by drug

Short acting: midazolam (Versed); propofol (Diprivan)

Control intermittent increases in ICP with a resultant decrease in CPP; improve oxygenation and ventilation

Analgesics

Varies by drug

Fentanyl (Sublimaze), morphine sulfate

Control intermittent increases in ICP with a resultant decrease in CPP

Independent

The highest priority is to maintain a patent airway, appropriate ventilation and oxygenation, and adequate circulation. Make sure the patient's endotracheal tube is anchored well. If the patient is at risk for self-extubation, maintain him or her in soft restraints. Note the lip level of the endotracheal tube to determine if tube movement occurs. Notify the physician if the patient's PaO2 drops below 80 mm Hg, if PaCO2 exceeds 40 mm Hg, or if severe hypocapnia (PaCO2 < 25 mm Hg) occurs.

Serial assessments of the patient's neurological responses are of the highest importance. When a patient's assessment changes, timely notification to the trauma surgeon or neurosurgeon can save a patient's life. The patient with DAI is dependent on nurses and therapists for maintaining muscle tone, joint function, bowel and bladder function, and skin integrity. Consult the rehabilitation department early in the hospitalization for evaluation and treatment. Frequent turning, positioning, and use of a pressure-release mattress help prevent alterations in skin integrity. Keep skin pressure points clean and dry.

Provide simple educational tools about head injuries. Referrals to clinical nurse specialists, pastoral care staff, and social workers are helpful in developing strategies to increase education and support. Establish a visiting schedule that meets the needs of the patient and family, while providing adequate time for patient care and rest. The mortality of patients with diffuse axonal injury ranges from 15% to 51%, with a wide variation in the level of cognitive functioning that the patient can reach through intensive rehabilitation. Education and support for the family are critical in assisting them in coping with severity of this injury.

Dislocation; Subluxation 291

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