CRIBS Treatment

Question 1

What are the 4 general steps of treatment for Mr. B?

Answer 1

1. page neurosurgery
2. reverse anticoagulation
3. decrease cerebral edema
4. Tx hypoxemia (likely due to blunt chest injury causing intraalveolar hemorrhage).

Question 2

How would we reverse the anticoagulation?

Answer 2

• transfuse pt with 4 units of FFP (already has clotting factors in it). Confirm with PT INR assay. We want INR to be 1.5 or lower or PT around 12 seconds.
• give 5-10 mg of Vitamin K IV to generate clotting factors 2, 7, 9, 10. Takes 24 hours to regenerate clotting factors.

Question 3

How does warfarin work?

Answer 3

• Inhibits liver epoxide reductase, thus interfering with y-carboxylation of vitamin K dependent clotting factors 2, 7, 9, 10 and proteins C and S. Monitor with PT/INR

Question 4

How can we decrease cerebral edema in our pt?

Answer 4

• change the settings on the ventilator in order to hyperventilate our pt, thus having him blow off more CO2.

Question 5

How will hyperventilating our pt help with his cerebral edema?

Answer 5

• decreasing the pCO2 will cause vasoconstriction (sensed by the carotid bodies) which will decrease cerebral perfusion pressure, thus lowering INTRACRANIAL PRESSURE.

Question 6

What is the equation for cerebral perfusion pressure (CCP)?

Answer 6

CCP= MAP - ICP

Question 7

What are the 4 possible ways to lower ICP using the ventilator settings?

Answer 7

1. increase FiO2 (fraction of inspired O2)= giving more O2. Remember atmospheric O2 is 0.21, so we can up this to 1 if we want.
2. increase positive end expiratory pressure (PEEP)= works by recruiting more alveoli to increase gas exchange.
3. increase minute ventilation by increasing tidal volume= normal inspiration and expiration (around 500 mL normally). This will decrease PCO2.
4. increase minute ventilation by increasing respiratory rate= decreases PCO2.

Question 8

What does decreasing PCO2 do to blood pH?

Answer 8

• increases pH of blood, also leading to vasoconstriction via the carotid bodies.

Question 9

What other ways can we lower ICP besides the ventilator settings?

Answer 9

• give 7.5 % hypertonic saline or mannitol (2 g/kg IV) over 30 minutes. This will pull fluid out of the intracranial space into the vasculature (basically dehydrating the cells).

Question 10

If the pt also has a pneumothorax/hemothorax, how would we treat that?

Answer 10

• chest tube placed at 5th intercostal space along the midaxillary line. Drain to gravity.

Question 11

Would you give Naloxone to reverse possible opioid overdose?

Answer 11

• Not in this case bc he is going to the OR and he’s already out, so we’ll keep the vecuronium and also add a general anesthetic like midazolam to keep the pt out.