This article was first published in the Winter 2021 issue of Critical Connections. 

A man in his early twenties was transferred to the intensive care unit (ICU) by his father for a second opinion after sustaining a gunshot wound to the head. Examination on arrival was consistent with severe traumatic brain injury (TBI) and central herniation syndrome. His Glasgow Coma Scale score was 3, he had no response to noxious stimuli, and he had fixed and dilated pupils. However, his gag reflex was intact. Neuroimaging studies confirmed skull bone fractures, intracranial hemorrhage, global cerebral edema, and central herniation.

Critical Connections, the critical care industry's only newsmagazine, provides information on cutting-edge topics in critical care useful to the entire multiprofessional team.Louanne M. Carabini, MD, MA, FASA
Kathy Johnson Neely, MD, MA, HEC-C