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Operated for acute subdural hematoma. Should I go for tracheostomy and gastrostomy tube insertion?

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Neurologist, Surgical
Practicing since : 1996
Answered : 146 Questions
My 62 year old father was operated for acute subdural hematoma six days back due to a fall. He has been in the ICU under sedation with fentanyl and propofol continuous infusion in addition to a broad spectrum antibiotic, keppra, BP medication plus some other side medication.

From a clinical history standpoint, he has two stents in the heart, has had hypertension, has parkinson's and also had grand mal/focal seizures
three months back which he almost recovered from.

He is also on ventilation with 25% oxygen. His ICP and BP are under control and the doctor decided to take the ICP monitors out. On neuro exams, pupil dilation has been reported as normal. When sedation is reduced, he raises his head & moves the body.
He opens & blinks the eyes but does not seem to focus his eyesight. Does not follow commands yet. We are told he also tried grabbing the tube when sedation was reduced today.

Looking at the CT, his mid-line shift has reversed to an almost normal position as compared to the original CT. There is a small remaining clot that was not operated on in the original surgery.

The Trauma team tried taking the tube for the ventilator out earlier today. Although his lungs performed well from a breathing perspective, the tube had to be re-inserted almost immediately as his airway closed and tongue (swollen) blocked the airway when the tube was taken out. He is also having excess salivation.

The trauma team requested our permission for Tracheostomy and Gastrostomy tube insertion. We were told that it will make it easier for taking him off the ventilator as well as help reduce the risk of infection.

I need your expert opinion on likely prognosis.
Posted Tue, 26 Mar 2013 in Brain Tumor
Answered by Dr. Praveen K Nath 4 hours later
Dear Sir,
Wishing a speedy & full recovery to your father
I have gone through your father’s history in detail. That he suffered a head injury with acute subdural haematoma which was operated & post op ventilation continued.
Re-intubation & re-ventilation is a known complication in these types of head injuries especially if a patient has a past history of parkinsons/ grandmal epilepsy/ old age / severe injury & tongue/ glottic oedema.
I would suggest that you to go ahead with tracheostomy. So that his proper airway is maintained & he can be weaned off ventilator faster after tracheostomy.
Tracheostomy can later be removed & hole heals by itself.

Regarding gastrostomy, you can wait for a while. Please discuss with your doctor regarding that.

I hope this answers most of your queries.

Wishing a speedy recovery.

Dr Praveen K Nath XXXXXXX consultant neurosurgeon
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