Patient 6 was a 71-year-old male pedestrian struck by a vehicle with reported field GCS = 14. The patient was intubated for airway compromise, and arrived at the trauma center with presentation GCS = 3T5. His primary survey revealed polytrauma with gross limb deformities and signs of craniofacial injury. A Focused Assessment with Sonography for Trauma examination was negative; CT of the head revealed diffuse traumatic SAH and a small falcine subdural hematoma. He was found to have coagulopathy by admission laboratory evaluation. After resuscitation and correction of coagulopathy, the patient was admitted to neurocritical care and an ICP monitor was placed. Repeat cranial imaging demonstrated worsening bifrontal contusions and an enlarging left temporal contusion. The patient's neurologic examination declined to GCS = 3T despite aggressive medical management for refractory ICP. A family discussion was held on day 2, at which time a DNR-CC order was activated. The patient was terminally extubated. The end-of-life recordings are shown in Figure C.
Patient 4, a 63-year-old man with previous myocardial infarction, hypertension, and diabetes mellitus, suffered from a CT-proven infarct of the complete right MCA territory. Decompressive hemicraniectomy was performed 37 hours after onset of the left-sided hemiparesis. On day 4, MRI additionally revealed infarcts in the vascular territories of the left MCA and right posterior inferior cerebellar artery as well as both cerebellar hemispheres. No SDs were recorded before the terminal one. A family discussion was held and a DNR-CC order was activated followed by terminal extubation on day 5. Figure B shows the nonspreading depression of activity during the falling phase of ptiO2. A very slow, homogeneous DC positivity started simultaneously with the drop in ptiO2. Superimposed on this DC positivity, the terminal SD then started at electrode 3.