Management of traumatic brain injury

Review course 2014Dr.Anand.M.TiwariIDCC,F.N.B Critical care medicine

anand tiwari reveiw course 2014


377 deaths daily.1356 –injury Yr 2012—1,38,245 deathYr 2013----1,37, 597



Prevention

Emergency Care

Critical Care

Brain specific therapy

MOI-


1.Auto strikes tree.2.Head strikes windshield.3.Brain strikes inside of frontal skull.4.Brain rebounds and hits inside of occiput.

(Contracoup Injury)

Diffuse axonal injury 24% mortality

Focal lesion 39% mortality



HypoxiaHypotensionHypocapnia Remember H

EffectHypercapniaHyperthermiaHypoglycemiaHyperglycemiaHypernatremiaHyponatremiaHyperosmolarity infections



Review of 25 studiesHEMS showed survival benefit in someWhich component??Methodology?

Assessment.

Intervention * suboptimal interventions.

50% patient extracrainal injuries.

Cervical clearance.



GCS RTS APACHE Pupillary diameter and reactivity Age Hypotension CT scan features



GCS 13– mild

GCS 9-13- Moderate.

GCS < 8 - Severe


Correction of reversible causes,Hypoxia,hypotension,c2h5oh intoxication

E V M*Sedationintubation


Field cervical spine clearance isnot possible with altered LOC

1

2 3

4

1

2

3

4


(a) a lateral view the base of the occiput to upper

border of first thoracic vertebrae,

(b) an anterior-posterior view C2 to T1 spinous processes. (c) an open-mouth odontoid view C1 lateral masses as well as the

whole odontoid process anand tiwari reveiw course 2014

2



Normal CT scan

Diffuse Axonal Injury


Patient continues to remain unconscious .

Mild DAI Moderate DAI Severe DAI

coma between 6 and 24 hours

coma for more than 24 hours without presence of decerebrate posturing

coma for more than 24 hours and with presence of decerebrate posturing as a motor response on nociceptive stimulation.anand tiwari reveiw course 2014


Definite role in defining shear injuries and for prediction of prognosis


FASTHUG


Give your patient a fast hug (at least) once a day.Vincent JL.

Crystalloids NS,RL

Colloids

Blood transfusion TriggerUse of vasopressor-

Dopamine/noradrenaline


Feeding ASAP ,<24 HRSHyper catabolicNG feed ? Orogastric tube Enteral

routeCan consider prokineticPEG long term


Perel P, Yanagawa T, Bunn F, Roberts IG, Wentz R. Nutritional support for head-injured

patients. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001530. DOI: 10.1002/14651858.CD001530.pub2.

Early nutritional therapy in trauma: after A, B, C, D, E, the importance of the F (FEED) Alberto Bicudo-Salomão, ACBC-MTI; Renata Rodrigues de MouraII; José Eduardo de Aguilar-Nascimento, TCBC-MTIII

Rev. Col. Bras. Cir. vol.40 no.4 Rio de Janeiro July/Aug. 2013


NeuroassesmentSedation vacation

Risk group- prolong sedation/extracranial injuries

Anticoagulant/LMWH___-????Look for –illeo femoralGraduated TED stockings/pneumatic

calf compressor unproven reasonable alternative


Head in neutral positionVenous drainageNo compression of neck veins by

tube tie


GCS charting frequentlyDaily fast hugHemodynamic monitoringFluid balanceBBB careBrain specific monitoringNeurosurgical consultation as

needed


BATTLE’S SIGN RACCOON EYES


CSF Fistule : Rhinorrhoea / Otorrhoea

Risk of meningitis*

** Early Rx -- Carbapenem .

**Topical (intrathecal or intraventricular) therapy colistin (off label ) for A.baumanii meningitis.

Craniofacial trauma

CSF leak new onset fever

Median time presentation 12 days.

suspicion of gram negative meningitis

124 Case Report- A.baumanii meningitis

Know your ICU/organism prevalent and resistant pattern

Preemptive antibiotics ????Stratify risk factorsSite specific ,bbb penetrationOther factors


Which mode?No permissive hypercapniaPeep ???

Weaning—Off ventilator does not mean

extubation


Hyperventilation

Euglycemia =<150mg% favarouable

Na Disturbances- SIADH CSW syndrome Diabetes insipidusCore temp-- Normal


CPP= MAP-ICP

70……BTF initial adoption*aggressive fluid/vasopressor..pulmonary complications

…60 anand tiwari reveiw course 2014


ICP MONITORING

Ocular ultrasound

Jugular bulb oximetry

Transcranial Doppler

Cerebral micro dialysis

Intracranial pressure monitoring 1.comatose patients with- Glasgow Coma Scale (GCS) 3-8 with abnormal

computed tomography (CT) scans

2.Normal CT scans with two or more of the following features at admission:

Age over 40, Unilateral or bilateral motor posturing, or A systolic blood pressure of less than 90 mm Hg.



] The optic nerve sheath diameter measurement was found to be well-correlated with the values of ICP and its value significantly increased to 7.0 ± 0.58 mm, when ICP rose in value to >20 mm Hg

EEG-SEP monitoring reflects to remaining metabolic activity of brain parenchyma.

EEG recordings usually get suppressed and difficult to interpret during deep sedation.


Surgical decompressionCSF drainageDecompressive craniectomyOsmotherapyHyperventilationHypotheramiaBarbiturate comaSteroidsCerebral vasospasm-nimodipineSeizure prophylaxis


Fig. 7. The Columbia stepwise protocol for ICP


MANNITOL

Single bolus & prolonged

Improves rheological value of RBCs & CPP

Rebound phenomenon.

Currently preferred

HYPERTONIC SALINE

Studies with single bolus & infusion …but limitations

Osmotic mobility decreases leukocyte adhesion.

Central pontine myelinosis (if hypoNa+)

??


?? Mannitol Vs H.S.?? Optimal conc. Of H.S.?? Outcomes of prolonged H.S. in raised ICP

MANNITOL 20%

.25-1 gm/kg @ prn Rheological effects Adverse effects

HTS 1.7%--29.2%

5% 2ml/kg 4-6 hrly. Serum osmolarity*-

320

Na*..155 meq/l



In this prospective evaluation of early PTS prophylaxis,

LEV did not outperform PHE.

Cost and need for serum monitoring should be considered in guiding the choice of prophylactic agent.



Discuss BTF guideline for surgery

An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patient's Glasgow Coma Scale (GCS) score.

An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning

close neurological observation in a neurosurgical center.



Discuss BTF guideline for evacuation??

An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a MLS greater than 5 mm on CT scan should be surgically evacuated, regardless of the patient's GCS score.

All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring.

A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and MLS less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg


Barbiturate coma BIS-5-20 EEG-Burst suppression.

Decompression craniotomy.Hypothermia 35*CSF drainageReconsider treatment.


Refractory casesDecrease CMRO2/Problem hypotension remember pearl harbor incidentAim till burst suppression on EEGGradual taper –delayed

awakening ,predispose patient to nosocomial infection



Awaits RESCUEicp results

reduces all cause mortality***

May be beneficial in improving neurological outcomesif cooling maintained for 48 hrs.



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Management of traumatic brain injury

Health & Medicine