Emergency Management of the Head Trauma Patient
Adam Schneider, DVMNeurology and Neurosurgery
Blue Pearl9500 Marketplace Rd
Fort Myers
Head trauma
• Common cause of morbidity and mortality
• 25% of blunt trauma injuries
• Dogs: 50% motor vehicle accidents
• Cats: 50% crush injuries
• May lead to traumatic brain injury (TBI)
Traumatic brain injury
”structural or physiologic disruption of the brain by external force”
Normal brain physiology
• Cerebral perfusion pressure (CPP)• CPP = MAP – ICP
• Cerebral blood flow (CBF)• CBF = CPP/CVR
• Cerebral vascular resistance (CVR)• CVR = L(n)/vessel diameter n = viscosity
• Autoregulation• Intrinsic ability of vasculature to maintain constant CBF and ICP over wide
range of pressure (50-150mmHg)
Autoregulation
• Pressure (sympathetic nervous system)
• Chemical (PaCO2)• Increased PaCO2 = vasodilation
• Example: hypoventilation
• Decreased PaCO2 = vasoconstriction• Example: hyperventilation
• Normal PaCO2 = 35-45 mmHg
Intracranial compliance
• Monro-Kellie hypothesis• ICP = Parenchymal volume + Blood volume + CSF volume
• Change in any one volume without compensatory decrease in others leads to increased ICP
• Head trauma• Adds hemorrhage and edema to the compartments
• Autoregulation lost
• Increase volume = increased ICP = decreased CPP(CBF) = ischemia and neuronal death 🙁
Primary brain injury
- Physical disruption of structures within skull at time of injury
- Beyond clinical control
Secondary injury
• Minutes to days
• All lead to increased ICP, decreased CBF, ischemia and neuronal death
Secondary injury
• Severely increased ICP leads to brainstem compression• Depressed mental, cardiac and respiratory function
• Brain herniation and death
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Cushing’s Reflex
• A.k.a cerebral ischemic response
• ↑ICP = ↓CBF and ↑CO2 -> systemic vasoconstriction (↑MAP) to maintain CPP
• Baroreceptors sense hypertension -> reflex bradycardia
• *Patients with decreased mentation, hypertension and bradycardia indicates increased ICP
• Time to treat!
Increased ICP
• Sudden decrease in mentation
• Pupillary light reflex/pupil size
• Decerebrate posture
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Modified Glasgow Coma Scale
• Validated in dogs
• 3 categories (score 1-6 each)• Motor activity
• Brainstem reflexes
• Level of consciousness
• Total score 18 (normal)
• MGCS of 8 w/in 48hrs = 50% chance survival
• *Designed for monitoring not predicting individual outcomes
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Imaging
• Extracranial
• Intracranial CT > MRI
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Fluid therapy
• ICP : MAP (when autoregulation lost)• Maintain systolic pressure >90mmHg
• Retrospective study (human): Single event of SBP <90mmHg = 150% increase in mortality
• Not exact science
• Pros/cons for all fluid types
• BBB not intact and brain is less tolerant of fluids
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Isotonic crystalloids (0.9%, P-lyte, LRS)
• Titrate to effect
• ¼ shock dose• 20ml/kg (dogs)
• 15ml/kg (cats)
• 0.9% NaCl (least amount of free water)
• Cons: • Acidifying (worsen acid-base status)
• Volume redistribution can worsen cerebral edema
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Colloids
• Supports plasma oncotic pressure to minimize extravasation
• Longer duration of action vs crystalloids
• Cons: • No clear benefit in major metaanalyses studies in people
• SAFE trial: 4% albumin significantly increased mortality vs 0.9% NaCl in TBI
• No studies with synthetic colloids (hetastarch) in TBI
• Some consider synthetic colloids fluid of choice in TBI
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Hyperosmolar Therapy: Hypertonic saline vs Mannitol
• Create osmotic gradient across the intact BBB
• Water shifts from interstitial space to intravascular space to decrease ICP
• Mannitol and Hypertonic saline routinely used
• Recent metaanalyses favors HTS, but controversy remains
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Hypertonic saline
• Several benefits• Rapidly expands intravascular space (patients in shock)
• Allows smaller volumes administered
• Reduces viscosity (CVR = L(n)/vessel diameter n = viscosity & CBF = CPP/CVR)
• Reduces endothelial swelling
• Modulation of neuroinflammatory pathways
• Duration: 75 minutes
• Cons:• Hypernatremic or hyponatremic patient
• Dose: 4ml/kg (7.5% NaCl); 5.4ml/kg (3% NaCl)
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Mannitol
• Sugar molecule• Acts as osmotic diuretic• Osmotic effect immediate
• Expands plasma volume and reduces viscosity, improving CBF• Persists 75 minutes
• Osmotic gradient crosses BBB in 15-30 mins, persists 2-5 hrs• Shifts fluid from brain to intravascular space
• Free radical scavenger• Cons:
• Diuretic effect: hypotensive patients and fluid correction must occur• Cannot use in hypovolemic patients
• Dose: 0.5-1g/kg over 20 mins (2 doses in 24 hours)
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Extravasation of Mannitol
• Concern for mannitol leaking into extravascular space • “reverse osmotic shift”
• Study: no difference found between patients with intracerebral hemorrhage that did or did not receive mannitol
• Unlikely with appropriate dosing
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Furosemide
• Historically given with mannitol to:• Decrease CSF production
• Counteract initial plasma expansion
• Potentiate the osmotic gradient
• Unproven
• May increase risk of dehydration and hypovolemia
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Anesthetics, Analgesics and Sedatives
• Analgesia essential in head trauma
• Balanced approach reduces risks of side effects
• ICP increases with inhalant anesthesia (>1-1.5 MAC)• Hypoventilation and hypercapnia also raise ICP
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Inhalant anesthesia
• Isoflurane
• MAC > 1-1.5 increases ICP
• Lower concentrations cause vasodilation which may improve CPP
• Contraindicated if ICP already increased• Recommend total IV anesthesia (e.g. propofol)
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Total Intravenous anesthesia
• Required for MRI, mechanical ventilation or refractory seizures
• Propofol is ideal (1-6mg/kg IV to effect, then 100-400mcg/kg/min)
• Study: Improved CPP and maintain pressure autoregulation better than inhalants
• Also may be neuroprotective• Via modulation of GABA receptors and antioxidant effect
• Cons: hypotension and hypoventilation
• Careful titration, meticulous monitoring and supportive care essential!
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Analgesia
• Patient comfort helps prevent further increases in ICP
• Pain and anxiety shown to increase cerebral metabolic rate• Increases CBF, blood volume and ultimately ICP
• Opioids – ideal (full mu agonists best)• Cardiovascular sparing
• Easily reversible
• Cons: respiratory depression
• Minimized with titration
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Fentanyl
• Less emetogenic than hydromorphone
• Fast acting and quickly wears off
• Reversible (if necessary)
• Cons: • requires CRI
• Becoming difficult to come by
• Dose • 2-6 mcg/kg loading dose followed by 2-6mcg/kg/hr CRI (dogs)
• 1-3 mcg/kg, then 1-3 mcg/kg/hr (cats)
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Ketamine
• Analgesic and hypnotic effects
• NMDA receptor antagonist• Neuroprotective role?
• Minimal respiratory depression
• Stimulate cardiovascular system
• Historically thought to increase ICP• New studies do not support this claim
• TBI studies suggest ketamine improves CPP and lowers vasopressor requirements
• Dose: 0.1 -1 mg/kg IV followed by 2-10 mcg/kg/min
• Combine with opioid
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Alpha-2 agonists
• Demedetomidine
• Reversible
• Provides sedation, anxiolysis, and analgesia
• Controversial in TBI
• Only used when others unavailable or not enough
• Dose: 0.5-3 mcg/kg, then 0.5-1 mcg/kg/hr
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Anticonvulsants
• Established correlation between severity of TBI and post traumatic epilepsy (PTE) as well as development of epilepsy compared with general population• Human medicine and 1 paper in veterinary medicine
• Early and late seizure development post injury (<7 or >7 days)
• Cochrane review evaluated prophylactic antiepileptic medications for prevention of early and late seizures (humans)• No evidence to support prophylactic use in preventing seizures.
• No studies in veterinary medicine
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Anticonvulsants - Benzodiazepines
• Diazepam, midazolam• 0.5-1 mg/kg IV
• Repeat 3 times, if having to repeat every 15-30mins start CRI• 0.25-1 mg/kg/hr
• Lower dose in patients with hepatopathy
• Increase dose for patients on phenobarbital
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Anticonvulsants - Levetiracetam
• Fast acting
• Emergency and maintenance medication
• Few side effects (sedation)
• No monitoring required
• Emergency dose: 60mg/kg IV, then 20mg/kg IV q8hr
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Anticonvulsants - Phenobarbital
• For refractory seizures that are not responding to benzodiazepines
• Dose: 4mg/kg q6hrs x 4 doses, then 2-3 mg/kg q12hrs
• Cons:• Injections are expensive
• Heavily sedating/coma
• Hepatotoxicity if not monitored
• Requires routine monitoring
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Anticonvulsants - Propofol
• Alternative for refractory seizures
• Use same guidelines for monitoring as previously noted
• Same dose as for anesthetic plane
• Requires intubation and mechanical ventilation
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Corticosteroids
• Once part of routine therapy for TBI
• CRASH trial results• Increased risk of death at both 2 weeks and 6 months in people
• NOT recommended for TBI patients
• When are they recommended?• Solu medrol (methylprednisolone) ONLY
• Decrease lipid peroxidase (free radical production)
• Within first 8 hours of Spinal Cord Injury
• Falling out of favor here too
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Corticosteroids
• Cause hyperglycemia• Studies: Hyperglycemia associated with poorer outcomes in patients with TBI
• Side effects• Ulcerations
• Diarrhea – dehydration, hypovolemia
• That being said…• Some studies still support the use of Solu-medrol in TBI
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Gastric ulcer prophylaxis
• Studies: • Neurologically injured patients are increased risk of gastric ulceration and bleeding(69)
• PPI and H2r antagonists effective in preventing GI bleeds in people
• No increase risk of nosocomial pneumonia (70)
• Proton pump inhibitors (PPI)*• Pantoprazole (injectable): 1mg/kg q24hrs
• Omeprazole (oral): <10kg = 10mg; >10kg = 20mg
• H2r antagonists• Famotidine: 0.5-1mg/kg PO or IV q12-24hrs
• *bonus effect: PPIs decrease CSF production (lower ICP)
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Oxygen and Ventilation
• Goals:• Sp02 > 94%
• Pa02 > 80mmHg
• Oxygen therapy• Individualized
• Nasal cannulas vs mask vs cage
• PaC02 most detrimental to CBF• Low C02 (<30mmHg)/hyperventilation = vasoconstriction = ischemia
• High C02 (>50mmHg)/hypoventilation/pulmonary contusion = vasodilation = increased ICP
• Prophylactic hyperventilation not recommended
• Normoventilation (PaCO2 35-40mmHg) ideal
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Nutrition
• Early support ideal
• Head trauma associated with hypermetabolic and hypercatabolic state
• Enteral nutrition• Supports GI integrity, immune function, decease stress
• Study: Retrospective found that nutritional support within 5 days reduced 2-week mortality and amount was inversely proportional to mortality
• Method of feeding dependent on patient mental status and ability to protect airway
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Head elevation
• Less than 30º ideal for reducing ICP, increasing CPP without affecting MAP
• Stiff board with towel underneath to avoid compressing jugulars and increasing ICP
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Therapeutic hypothermia
• Secondary brain injury inhibited by hypothermia (90 –93)ºF
• Standard of care in people for stroke, cardiac arrest, intracranial hypertension with status epilepticus
• Recent study showed no benefit for TBI with intracranial hypertension
• 1 case report in Veterinary medicine
• Current recommendation:• If head trauma patient is hypothermic, allow passive rewarming
• Do not actively cool
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Glycemic control
• Hyperglycemia leads to (humans):• increases in mortality and duration of hospitalization
• Worse neurological outcome
• Veterinary medicine, hyperglycemia is indication of severity• Not a prognostic indicator
• Insulin therapy not recommended
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Overview of head trauma stabilization
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Surgical treatment options - Case
• Chanel, 3yr FS Chihuahua
• Fell off stool
• Brought to family veterinarian for status epilepticus and dent in head since fall
• Family veterinarian called SVS for advice
• Not responding to valium
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Chanel
• Recommended propofol CRI and ambulance ride to SVS!
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Chanel
• Upon arrival Chanel intubated
• Phenobarbital load and levetiracetam
• Neurologic exam – limited!
• Next step…
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Chanel
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Decompressive craniectomy
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Post-operative
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Ideally…
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References• Platt S, Radaelli S, McDonnell J. The prognostic value of the Modified Glasgow Coma Scale in head trauma in dogs. J Vet Intern Med 2001;15(6):581–4.
• Dewey CW. Emergency management of the head trauma patient. Principles and practice. Vet Clin North Am Small Anim Pract 2000;30(1):207–25.
• DiFazio J, Fletcher DJ. Updates in the management of the small animal patient with neurologic trauma. Vet Clin North Am Small Anim Pract 2013;43(4):915–40.
• Kuo K, Bacek L. Head Trauma. Vet Clin Small Anim 48 (2018) 111–128
• Sande A, West C. Traumatic brain injury: a review of pathophysiology and management. J Vet Emerg Crit Care (San Antonio) 2010;20(2):177–90.
• Sharma D, Holowaychuk M. Retrospective evaluation of prognostic indicators in dogs with head trauma: 72 cases (January–March 2011). J Vet Emerg Crit Care (San Antonio) 2015;25(5):631–9.
• Lagares A, Ramos A, Pe ́rez-Nun ̃ez A, et al. The role of MR imaging in assessing prognosis after severe and moderate head injury. Acta Neurochir 2009;151(4): 341–56.
• Beltran E, Platt SR, McConnell JF, et al. Prognostic value of early magnetic resonance imaging in dogs after traumatic brain injury: 50 cases. J Vet Intern Med 2014;28(4):1256–62.
• SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, George Institute for In- ternational Health, Myburgh J, Cooper DJ, Finfer S, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007; 357(9):874–84.
• Misra UK, Kalita J, Ranjan P, et al. Mannitol in intracerebral hemorrhage: a randomized controlled study. J Neurol Sci 2005;234(1–2):41–5.
• Roberts A, Pollay M, Engles C, et al. Effect on intracranial pressure of furosemide combined with varying doses and administration rates of mannitol. J Neurosurg 1987;66(3):440–6.
• McCulloch T, Visco E, Lam A. Graded hypercapnia and cerebral autoregulation during sevoflurane or propofol anesthesia. Anesthesiology 2000;93(5):1205.
• Zeiler FA, Teitelbaum J, West M, et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014;21(1):163–73.
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Questions?
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