Controversial treatment of a victim of severe head injury complicated by septic shock and acute respiratory distress syndrome

Anniken Haavind¹, Olav Hevrøy¹, Rune Hennig^2,3, Lars Bjertnaes^1,3
1Division of Intensive Care Medicine, Department of Anesthesiology; ²Department of Neurosurgery, University Hospital of North Norway; ³Department of Clinical Medicine (neurosurgery and anesthesiology), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway

Abstract: Pneumonia, severe sepsis, and acute respiratory distress syndrome (ARDS) are frequent complications after head trauma. Recombinant human activated protein C (APC) reportedly improves circulation and respiration in severe sepsis, but is contraindicated after head injury because of increased risk of intracranial bleeding. A 21-year-old man with severe head injury after a car accident was endotracheally intubated, mechanically ventilated, and hemodynamically stabilized before transfer to our university hospital. His condition became complicated with pneumonia, septic shock, ARDS, coagulation dysfunction, and renal failure. In spite of intensive therapy, oxygenation and arterial blood pressure fell to critically low values. Simultaneously, his intracranial pressure peaked and his pupils dilated, displaying no reflexes to light. His antibiotic regimen was changed and ventilation was altered to high frequency oscillations, and despite being ethically problematic, we added APC to his treatment. The patient recovered with modest neurological sequelae.

Keywords: activated protein C, acute respiratory distress syndrome, septic shock, severe head injury