tbi-case: added the therapeutic timeline table

Author: pavl-library

modules/CASES/pages/dai.adoc

@@ -259,6 +259,116 @@ incrementally as the patient was having sub-clinical fits in the abnormal extens
 
 == Therapeutic Timeline:
 
+[.black-header, options="header"]
+|===
+| Timeline | Admission Day | 2^nd^ Day | 3^rd^ Day | 4^th^ Day | 5^th^ Day
+ 
+| Oxygenation & Intubation
+a|
+* Suctioning & ventilatory care for the pre-intubated tube.
+* Mechanical ventilation to maintain the following parameters: PaO~2~ = 100 mm.Hg; PaCO~2~ = 35 mm.Hg; SPO~2~ >= 95%; RR = 12 Bpm.
+* Hyperventilation is not recommended, and should be used cautiously as it depletes carbon dioxide leading to cerebral vasoconstriction impairing the CBF worsening the brain condition.
+|
+|
+|
+| Tracheoesophageal fistula with a severe paroxysmal fall in SPO~2~ to below 60%, upper respiratory tract stridor, and abdominal breathing sounds.
+ 
+| Respiration/PEEP
+a|
+* PEEP provides an added positive supportive pressurization at the end of the expiration phase to maintain the pulmonary inflation avoiding alveolar collapse.
+* PEEP provides protection against ARDS (Acute Respiratory Distress Syndrome).
+* PEEP adjusted to 14--15 cm.H~2~O pressurization parameters to prevent the increase in ICP.
+|
+|
+|
+|
+ 
+| Hemodynamic support
+a|
+Maintenance of the following parameters: +
+SBP >= 110 mm.Hg +
+Hemoglobin >= 7 g/dL +
+pH = 7.35--7.45 +
+Serum sodium = 135--145 mEq/L
+|
+|
+|
+|
+ 
+| Glucose, Thiamine & Neurotonics
+a|
+* Maintenance of the glucose levels between (80--180) mg/dL, by adding 25 gm glucose via 50% dextrose IV solutions.
+* Thiamine 100 mg should be administered with glucose to avoid Wernicke's Encephalopathy.
+|
+|
+|
+|
+ 
+| Seizures
+| An initiative loading dose of Levetriacetam 500 mg/100 mL Saline 0.82% IV b.d for 15 minutes. +
+Carried-out an EEG image.
+| Maintenance dose of Levetriacetam 1000 mg/100 mL Saline 0.75% IV o.d for 15 minutes. +
+Carried-out an EEG image.
+| Further increase up-to 1500 mg/100 mL Saline 0.54% IV o.d for 15 minutes.
+|
+|
+ 
+| Anti-High ICP measures
+a|
+Maintenance of the ICP pressurization below 20 mm.Hg is recommended to prevent the steep decrease of CPP; as CBF = CPP/CVR, and CPP = MAP - ICP.
+|
+|
+|
+|
+ 
+| Venous Thromboembolism Prophylaxis
+|
+| Enoxaparin (Clexane) 40 mg o.d subcutaneously, an anti-factor Xa level can be measured to adjust the dose accordingly.
+|
+|
+|
+ 
+| Body Temperature
+a|
+General measures to keep the patient normothermic (37 deg. Celsius), e.g: Paracetamol IV.
+|
+|
+|
+|
+ 
+| Physical Examination (Coma score & Brainstem status)
+a|
+* GCS = 4/15, E1-V1-M2
+* PRS = 2 (Both pupils aren't reactive to light).
+* GCS-P = GCS - PRS = 2.
+* Maintenance of extensor posture on applying external stimulus.
+* Hyperreflexia
+* Hypertonia
+* Loss of brainstem reflexes (light reflexes -- oculovestibular reflexes -- corneal reflexes)
+* Left Sustained ankle myoclonus
+* Bilateral absent plantar flexion reflex (absent Babinski sign).
+|
+|
+|
+a|
+* GCS = 3/15, E1-V1-M1
+* PRS = 2.
+* GCS-P = 1.
+* Areflexia
+* Flaccid Paralysis
+|===
+ 
+[.subtitle, cols="1,3", frame=none, grid=none]
+|===
+| CBF | Cerebral blood flow
+| CVR | Cerebrovascular resistance
+| CPP | Cerebral perfusion pressure
+| MAP | Mean Arterial pressure
+| PEEP | Positive-end-expiratory pressure
+| PRS | Pupillary light reactivity score; 2 if both pupils are non-reactive
+| GCS-P | Glasgow coma scale pupils score
+|===
+
 == Discussion:
 The evidence from history, physical examination, signs, and diagnostics are all collectively suggestive of a diffuse axonal injury as a result of traumatic brain injury. The physical theory, that highly ascertains the condition, is the abrupt deceleration forces being applied on an accelerating body, these types of forces can be triggered by sudden flips in the direction of the speed of the body ^<<acc-dec-mode,[6]>>^.