A case report of successful treatment of severe traumatic brain injury by prolonged targeted temperature management

摘要

To the Editor: A 19-year-old Chinese woman presented with a coma after a traffic accident on August 22, 2019. After the injury, she was moved to Guangxi University of Traditional Chinese Medicine First Affiliated Hospital with a diagnosis of severe traumatic brain injury (sTBI) with cerebral herniation [Figure ​[Figure1A]1A] and underwent craniotomy evacuation of hematoma and decompressive craniectomy twice. The patient was transferred to the intensive care unit (ICU) two days after the surgery. She has been in a coma since sTBI, and her other medical histories were unremarkable. On physical examination at admission, with a Glasgow Coma Scale (GCS) of 3, her vital signs showed a temperature of 35.3°C, blood pressure of 151/128 mmHg, and pulse of 90 beats/min. Her pupils were 3.5 mm in diameter and reactionless. A surgical scar was observed on the right side of the skull, and the missing part of her skull measured 10 cm × 10 cm. Two drainage tubes were implanted in the epidural space. She had undergone a tracheotomy and was given sedation and ventilator breathing, with a peripheral oxygen saturation of 100% on 50% fraction of inspired oxygen. Pathological signs were negative, and corneal reflex could not be elicited. There was skin abrasion on her waist, buttocks, and left hand. Other physical examination findings were unremarkable. Laboratory work was significant, with a procalcitonin (PCT) of 0.688 μg/L, high-sensitivity C-reactive protein (CRP) of 48.04 mg/L, CRP of >10 mg/L, creatine kinase of 1259 U/L, interleukin 6 of 31.62 pg/mL, hemoglobin of 92.3 g/L, white blood cell count of 15.3 × 109/L, neutrophil count of 14.24 × 109/L, platelet count of 140.6 × 109/L, and bilirubin of 4.8 μmol/L. Other laboratory findings were unremarkable. Computed tomography (CT) scan of the head showed epidural and subdural hematomas and severe cerebral edema with loss of sulci/gyri differentiation [Figure ​[Figure1B].1B]. To reduce oxygen consumption and alleviate brain edema and secondary damage to the nervous system, we immediately placed the patient under targeted temperature management (TTM) in addition to standard treatments, including mechanical ventilation, neuro-nutrition, osmotherapy, and prophylactic antimicrobial therapy of sTBI. The device for TTM we supplied was an ARCTIC SUN® 5000 Temperature Management System (Bard Medical, USA). The initial target temperature was set at 35 to 36°C; we used a cooling blanket to achieve the goal temperature and a nasal probe to continuously monitor the brain temperature. Arteries ice compressions, alcohol bath, and antipyretic were also provided in case of non-ideal effects of the cooling device. At the same time, we provided propofol 50 mg and dezocine 2.5 mg every 1 h for continuous sedation and analgesia and atracurium 1 μg/kg every 1 min for intermittent muscle relaxation to reduce man-machine confrontation and muscle fibrillation. During the treatment, the patient's vital signs were stable, and her body temperature was maintained in the ideal range; she was well adapted to the ventilator, the ventilation parameters were gradually decreased, the bispectral index (BIS) monitoring indicated that her consciousness was gradually regained, and the changes in PCT values showed no increased risk of infection. The trends in body temperature, PCT, and BIS during TTM are shown in Figure ​Figure1F.1F. The epidural drainage tubes were removed on day 9 of admission and the incision healed well. The repeated head CT on day 4 [Figure ​[Figure1C]1C] and day 13 [Figure ​[Figure1D]1D] showed that the cerebral edema was alleviated gradually, and then the target temperature was set to 36 to 37°C; the patient was then weaned from the ventilator and sedative and analgesic drugs. The patient regained consciousness on day 15, and she received inpatient pulmonary rehabilitation and physical exercises on day 19. TTM was terminated on day 22 after repeat CT showed complete resolution of the brain edema [Figure ​[Figure1E],1E], and the tracheal tube was removed on day 29. During TTM, no serious muscle fibrillation, coagulation disorder, bleeding events, arrhythmia, hypotension, gastric retention, delayed wound healing, or other complications occurred. Continuous monitoring of coagulation indicators and platelet counts showed no abnormalities. The patient was able to pull herself to the standing position and was able to sit down on her own on day 36, after which she was transferred to the general ward. After a half month of rehabilitation, she was able to walk independently and complete activities of daily living and was discharged on October 17, 2019.