My name is Patrik Hutzel from intensivecarehotline.com and this is another quick tip for families in intensive care. Here at intensivecarehotline.com, we instantly improve the lives for families of critically ill patients in intensive care so that you can make informed decisions, have peace of mind, control, power, and influence — making sure your loved one always gets the best care and treatment in intensive care, even if you are not a doctor or a nurse in intensive care.

Angela reached out to us with a heartbreaking situation. Her boyfriend recently hung himself, was found without oxygen for approximately 20 minutes, and is now in the ICU in critical condition. His organs are showing some improvement, but every time the team tries to reduce sedation, he shows no physical response to stimulation — and his heart rate climbs while his blood pressure drops, forcing the team to resedate him. Scans show brain swelling.

Angela wants to understand what this all means for his recovery, and what questions she should be asking the ICU team.

This blog post and accompanying YouTube video are for Angela and every family in a similar situation. I am going to break this down clearly, clinically, and honestly — because you deserve the truth, not just reassurance.

IMPORTANT

This article is for educational and advocacy purposes only. It is not a substitute for advice from your loved one’s treating medical team.

Every patient is different. What I describe here are general principles — your specific situation may vary significantly.

If you need personalized guidance, please reach out to us at Intensive Care Hotline.

1. What Happened Physiologically? Anoxic vs. Hypoxic Brain Injury

The first thing families need to understand is the difference between an anoxic and a hypoxic brain injury — because in a hanging, it can be either, and it matters enormously for prognosis.

Anoxic Brain Injury — If His Heart Stopped

If Angela’s boyfriend experienced a cardiac arrest at the time of the hanging, his brain received zero oxygen for a period of time. This is called an anoxic brain injury — ‘anoxic’ meaning no oxygen at all. The brain is extraordinarily sensitive to oxygen deprivation. After just 4–6 minutes without blood flow and oxygen, brain cells begin to die. At 20 minutes without oxygen delivery, the extent of injury can be severe and widespread.

However — and this is critically important — the extent of the injury is not always fully known in the early days. Brain swelling (cerebral oedema) in the acute phase can mask what is actually intact underneath. Families are sometimes given worst-case information very early that does not reflect the eventual outcome.

Hypoxic Brain Injury— If His Heart Kept Beating

If his heart continued to beat throughout — which can happen in a hanging where the airway is obstructed but circulation continues — the brain received reduced but not completely absent oxygen. This is a hypoxic brain injury. While still serious, hypoxic injury can sometimes be less globally severe than anoxic injury because there was still some oxygen delivery occurring.

In Angela’s case, it is not yet clear which scenario applies — and this is one of the first things to clarify with the ICU team.

KEY QUESTION FOR THE ICU TEAM

“Was there a cardiac arrest at the time of the event, or did his heart continue to beat throughout?”

This distinction directly affects prognosis and the interpretation of his brain scans and current neurological status.

2. What Does Brain Swelling (Cerebral Oedema) Mean?

When the brain is deprived of oxygen, the cells that survive begin to swell as part of the injury response. This swelling — called cerebral oedema — is itself dangerous because the brain is enclosed in the rigid skull. Swelling increases pressure inside the skull (raised intracranial pressure or ICP), which can compress healthy brain tissue and reduce blood flow further.

The ICU team will be monitoring and managing this carefully. Treatments may include:

• Positioning — keeping the head of the bed elevated
• Osmotherapy — medications like mannitol or hypertonic saline to draw fluid out of brain tissue
• Sedation and controlled ventilation — to reduce metabolic demand on the brain and control CO? levels (which directly affect cerebral blood vessel diameter)
• Temperature management — controlled cooling (targeted temperature management or TTM) to reduce brain metabolic activity

ICP (Intracranial pressure monitoring) — in some cases, a probe may be placed to directly measure pressure inside the skull

The presence of swelling on the scan does not in itself tell you the final outcome. What matters is the trajectory — is the swelling improving, stable, or worsening? And what does the pattern of injury look like on more detailed imaging?

WHAT TO ASK THE TEAM

“Is the brain swelling improving, stable, or getting worse?”

“What is his intracranial pressure, and how are you managing it?”

“Has he had an MRI as well as a CT scan? MRI gives much more detailed information about the extent of brain injury.”

3. Why Is He Not Responding When Sedation Is Reduced?

This is the part of Angela’s message that I know is the most frightening — every time the team tries to wake him up, he shows no physical response to stimulation, his heart rate goes up, and his blood pressure drops. Let me explain what may be happening.

No Response to Stimulation

In the early stages after a significant brain injury, the absence of response to stimulation does not necessarily mean there is no brain activity at all. The brain injury, the ongoing sedation medications still in his system, the metabolic stress on his body, and the brain swelling can all suppress visible neurological responses. It is very common in the first days to two weeks after a severe hypoxic or anoxic brain injury for patients to show little or no meaningful response even when sedation is reduced.

Neurological assessment in this phase is notoriously difficult, and premature prognostication — being told too early that there is no hope — is a known problem in ICU settings. This is not a criticism of individual clinicians; it is a recognized challenge in the field.

Heart Rate Up, Blood Pressure Down

When sedation is reduced and the patient shows cardiovascular instability — heart rate rising, blood pressure falling — this is called hemodynamic instability on sedation reduction. This can reflect that the nervous system is not yet able to regulate itself adequately. It tells us the patient’s body is under significant physiological stress. The team re-sedates because continued hemodynamic instability is itself dangerous. This is appropriate management in the acute phase.

It does not necessarily mean he will never come off sedation. It means it is too early right now.

WHAT FAMILIES NEED TO UNDERSTAND

Neurological prognosis after hypoxic/anoxic brain injury is most reliably assessed at 72 hours or later — and even then, some patients continue to improve for weeks.

Premature withdrawal of treatment based on early assessments is a real risk. You have the right to ask for more time and more comprehensive assessment.

The internationally recognized guidelines (such as those from the European Resuscitation Council) recommend multi-modal assessment over time — not a single early test or scan.

4. What Is the ICU Team Assessing? Key Tests and Investigations

For Angela’s boyfriend, the ICU team should be conducting or considering the following assessments — and you have every right to ask about each of them:

• Brain Imaging
• CT scan (already done) — shows structural changes, bleeding, and gross swelling
• MRI brain — far more sensitive for detecting the pattern and extent of hypoxic/anoxic injury. This is critical. If he has not had an MRI, ask why and when this will happen.
• Neurophysiology
• EEG (electroencephalogram) — measures electrical brain activity. Can detect seizure activity (which is common after brain injury and can worsen outcomes if untreated), and gives information about the degree of brain function
• Evoked potentials (specifically SSEPs — Somatosensory Evoked Potentials) — tests how signals travel from the body through the spinal cord to the brain. Certain patterns on SSEPs are used in prognostication after cardiac arrest
• Blood Tests
• NSE (Neuron-Specific Enolase) — a biomarker released by damaged brain cells. Elevated levels at 48–72 hours are used as part of prognostication in cardiac arrest survivors, though it must be interpreted alongside other data
• Metabolic panel — kidneys, liver, lactate, electrolytes — all affect brain function and recovery
• Clinical Neurological Examination
• Pupil responses to light
• Corneal reflexes
• Response to painful stimulation
• Spontaneous movements
• GCS (Glasgow Coma Scale) (228) scores over time

CRITICAL POINT

No single test or finding should be used in isolation to make a prognosis.

The internationally accepted approach is multi-modal — combining clinical examination, imaging, neurophysiology, and biomarkers over time.

If you feel decisions are being made based on limited information, you have the right to request a formal neurological consultation and a second opinion.

5. What Are the Possible Outcomes? Honest and Realistic

Families deserve honesty. I am not going to give you false hope, and I am not going to tell you there is no hope. The reality is that at this stage — early in the ICU admission, with ongoing brain swelling and hemodynamic instability — the outcome is genuinely uncertain.

Here is the realistic range of outcomes after a significant hypoxic or anoxic brain injury at approximately 20 minutes:

Scenario A — Meaningful Recovery

Some patients do recover meaningful function after prolonged hypoxia or anoxia. This is more likely when: the injury was hypoxic rather than anoxic (heart beating throughout), the patient is younger, organ function is recovering (as Angela notes his organs are improving), and the pattern of injury on MRI is less extensive than initially feared. Recovery in these patients can take weeks to months and typically involves intensive rehabilitation.

Scenario B — Disorders of Consciousness

Some patients progress to a prolonged disorder of consciousness — either a vegetative state (no awareness of self or environment) or a minimally conscious state (some evidence of awareness, but inconsistent). These patients may survive long-term but require full nursing and medical support. Distinguishing between these states requires specialist assessment and takes time — often weeks to months.

Scenario C — The Brain Injury Is Not Survivable

In some cases, the extent of the brain injury is ultimately incompatible with survival or with any meaningful brain function. In these situations, the ICU team may raise the question of withdrawal of life-sustaining treatment. This is one of the most difficult conversations any family will ever face — and you should never feel pressured into a decision before you are ready, and before comprehensive assessment has been completed.

YOUR RIGHTS AS NEXT OF KIN

You have the right to ask for all medical records — including scan reports, nursing notes, blood results, and specialist consultation notes.

You have the right to ask for a second neurological opinion.

You have the right to ask for more time before any decision about withdrawal of treatment is made.

You have the right to have someone advocate for you in conversations with the medical team.

6. The Importance of Getting All Medical Records

One of the most powerful things you can do as a family member in ICU is to obtain all medical records. I say this to every family I work with, without exception.

Medical records give you access to the actual data — not just the summary the team shares in a brief family meeting. They allow you and any advisors, second-opinion consultants, or advocacy services to understand the full clinical picture.

In Angela’s situation, the records to request include:

• All CT and MRI scan reports (radiology reports)
• All neurological consultation notes
• EEG and evoked potential reports if performed
• Daily ICU nursing and medical progress notes
• All blood test results including NSE levels
• The ICU treatment plan and any documentation of prognosis discussions

You are legally entitled to these records. If you need help understanding them or using them to advocate effectively, this is exactly what we do at Intensive Care Hotline.

7. How a Consulting Call with Intensive Care Hotline Can Help

At Intensive Care Hotline, my team and I work with ICU families in exactly this situation every week. We can:

Help you understand the medical records and what they actually mean

Prepare you with the right questions to ask the ICU team — in the right way

Join a call with you and the ICU team to question, clarify, and advocate on your behalf

Help you understand your rights around second opinions, withdrawal of treatment decisions, and transfer of care

Help you navigate the difference between what the team is telling you and what the evidence actually says about prognosis

We have helped hundreds of families avoid premature withdrawal of treatment, secure second opinions, and make fully informed decisions — whether that means fighting for more time, or understanding when it is time to let go.

CONTACT US

www.intensivecarehotline.com call us, email us to [email protected]

Or book a consulting call with me https://intensivecarehotline.com/scheduling-appointment/

We are available seven days a week.

8. What If He Survives But Cannot Be Weaned Off the Ventilator?

This is a question many families face when a loved one survives a critical brain injury but is left ventilator-dependent or tracheostomy-dependent. The ICU is not a long-term care environment. But hospital is not the only option.

At Intensive Care at Home — Australia’s only third-party accredited specialist Intensive Care at Home provider — we support ventilator-dependent adults and children to live at home, safely and with full clinical oversight. We also work with families in the USA, UK& Canada, please reach out to us.

We support patients who:

• Require long-term invasive mechanical ventilation (via tracheostomy)
• Require long-term non-invasive ventilation (BiPAP, CPAP, NIV)
• Have a tracheostomy and cannot yet be decannulated
• Are in a disorder of consciousness but are medically stable enough for home care
• Require palliative care with ongoing ventilatory support

Home-based intensive care is not a step down in care. It is a different care environment — one that allows families to be present, that removes the patient from the institutional ICU environment, and that for many patients, enables a better quality of life.

ICAH is NDIS registered, ISO 9001:2015 certified, and BSI Group audited — with zero non-conformances at our most recent audit. We operate across all states and territories within Australia but also help families in the USA, Canada and the UK. Please contact us.

INTENSIVE CARE AT HOME — FOR FAMILIES PLANNING AHEAD

If your loved one survives but requires long-term ventilation, home care is a real, proven, and accredited option.

Visit www.intensivecareathome.com to learn more.

Or call us to speak with our team about whether home care could be right for your family.

9. Questions Angela Should Be Asking the ICU Team Right Now

To summarize everything above, here are the key questions I would want Angela to bring to her next family meeting:

• Was there a cardiac arrest at the time of the event, or did his heart keep beating? (Anoxic vs. hypoxic injury)
• Has he had an MRI of the brain yet? If not, when will this happen?
• Has an EEG been performed to look for seizure activity? What did it show?
• Have evoked potentials (SSEPs) been done as part of neurological prognostication?
• What is his NSE level at 48–72 hours, and how is this being interpreted?
• Is the brain swelling improving, stable, or worsening?
• What is your multi-modal prognostication plan and timeline? At what point will you make a formal neurological prognosis?
• Can I have copies of all medical records including scan reports, blood results, and specialist notes?
• Can we arrange a formal family meeting with the neurologist — not just the ICU team — to discuss prognosis?
• If he survives but cannot be weaned off the ventilator, what long-term options exist?

How We Can Help You Right Now

If you are in Angela’s situation, or something similar — please do not navigate this alone. The ICU is a complex, high-stakes environment, and families who have access to expert advocacy and guidance consistently make better-informed decisions.

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy because of our insights. You can verify that on our testimonial section at intensivecarehotline.com. You can verify it on our intensivecarehotline.com podcast section where we have done client interviews because our advice is absolutely life changing.

The biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care.

That’s why we help you to improve your life instantly, making sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always. That’s why you can join a growing number of members and clients that we have helped over the years, saving their loved ones’ lives.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. When I talk to families directly, I also talk to doctors and nurses directly, asking all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.

I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if in case you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care, and you can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded. All of that will help you to improve your life instantly, make informed decisions, have peace of mind, control, power and influence, making sure your loved one gets best care and treatment always.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.