A male patient who is 5'10" and weighs 190 lb arrives at the hospital having suffered a closed head injury in a motor vehicle accident

The patient is unconscious and a computer tomogram of the head reveals an intracranial bleed. The patient receives an intracranial pressure (ICP) monitor following neurosurgery. Initial venti-lator settings should include which of the following?
a. Volume-controlled continuous mandatory ventilation (VC-CMV), respiratory fre-quency (f) 15 breaths/min, tidal volume (VT) 750 mL, positive end-expiratory pressure (PEEP) 5 cm H2O, fractional in-spired oxygen (FIO2) 1.0
b. Pressure-controlled continuous mandatory ventilation (PC-CMV), f 15 breaths/min, peak inspiratory pressure (PIP) 35 cm H2O, PEEP 10 cm H2O, FIO2 1.0
c. Volume-controlled intermittent mandatory ventilation (VC-IMV), f 6 breaths/min, VT 300 mL, pressure support (PS) 10 cm H2O, PEEP 5 cm H2O, FIO2 0.50
d. Pressure-controlled intermittent mandato-ry ventilation (PC-IMV), f 12 breaths/min, PIP 20 cm H2O, PS 10 cm H2O, PEEP 5 cm H2O, FIO2 0.40

ANS: A
The initial settings for a closed head injury patient include pressure-controlled (PC) or vol-ume-controlled (VC) continuous mandatory ventilation (CMV), tidal volumes between 8 and 12 mL/kg, respiratory frequency (f) 15-20 breaths/min, positive end- expiratory pressure (PEEP) 0-5 cm H2O with caution and higher only if there is severe hypoxemia, and fractional inspired oxy-gen (FIO2) 1.0 to start and titrate to keep partial pressure of oxygen (PaO2) between 70 and 100 mm Hg. This eliminates both intermittent mandatory ventilation (IMV) choices. The PC-CMV choice has a peak inspiratory pressure (PIP) and PEEP that are too high for this type of patient because it would increase intracranial pressure (ICP). Choice "A" fits within the guideline for ventilation of the closed head injury patient.