5. Classification Severity Minimal : GCS 15, no LOC or amnesia Mild : GCS 14, or 15 + LOC or amnesia impaired alertness or memory Moderate : 9-13 or LOC ≥ 5 min or focal neurological deficit Severe : GCS 5 - 8 Critical : GCS 3 - 4
40. Managing raise ICP General measure Medical management Surgical intervention
41. General measure Head elevation Maintain normal temperature Neck vein compression? ? Chest Physio Hyperventilation Fluid management Glucose monitor Maintain normal Blod pressure
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44. Maintain normal temperature Keep patient’s body temperature within normal limit
45. ? Chest Physio To give sedation during chest physiotherapy
46. Hyperventilation NO HYPERVENTILATION !!!! Keep patient at the lower limit of normocapnia (32mmHg) Optimal Oxygenation !!! Increased CO2 = Vasoconstriction and Decreased ICP Decreased CO2 = Vasodilatation and Increased ICP
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49. Medical management Sedation Muscle relaxant Barbiturate & Propofol analgesic antipyretic Mannitol & Frusemide Hypertonic saline antiepileptics Neuroprotective agent BP control
51. Barbiturate & Propofol Barbiturates appear to exert their ICP-lowering effects through vasoconstriction, which results in a reduction in CBF and CBV secondary to the suppression of cerebral metabolism
53. Mannitol & Frusemide The administration of mannitol has become the first choice for pharmacological ICP reduction , Mannitol has an immediate plasma-expanding effect that reduces haematocrit and blood viscosity and increases CBF and cerebral oxygenation delivery. Hyperosmotic agents remove more water from the brain than from other organs because the blood–brain barrier impedes the penetration of the osmotic agent into the brain maintaining an osmotic diffusion gradient. This osmotic effect of mannitol is delayed for 15–30 min. Mannitol consistently decreases ICP for 1–6 h.
54. Mannitol & Frusemide An ultra-early single-shot administration of high-dose mannitol (1.4 g/kg) in the emergency room significantly improves the 6-month clinical outcome after head injury One risk of hyperosmotic agents is the rebound effect, which might increase ICP. To reduce this risk it is recommended that mannitol should be administrated as repeated boluses rather than continuously, only in patients with increased ICP and not longer than 3–4 days As mannitol is entirely excreted in the urine there is a risk of acute tubular necrosis, particularly if serum osmolarity exceeds 320 mOsmol/l
55. Mannitol & Frusemide Although furosemide itself has only a minimal effect on ICP, in combination with mannitol it enhances the effects of mannitol on plasma osmolality, resulting in a greater reduction of brain water content
56. Hypertonic saline Several studies have shown that hypertonic saline is equal or even superior to mannitol in reducing ICP. Vialet et al. suggested that hypertonic saline (2 ml/kg, 7.5%) is an effective and safe initial treatment for intracranial hypertension episodes in head trauma patients when osmotherapy is indicated. Even very high concentrated hypertonic saline solutions (23.5%) can be used and can reduce ICP in poor grade patients with subarachnoid haemorrhage.
57. antipyretic antiepileptics Neuroprotective agent it is evident that hyperthermia should be avoided Is not for reduce ICP. But to prevent fit which will cause raise ICP Still under experimental stage
58. Surgical intervention Removal of the pathological lesion CSF diversion procedure Open the cranium “ craniectomy” Remove part of the non-eloquent brain “ Lobectomy”
59. Removal of the pathological lesion CSF diversion procedure Open the cranium “ craniectomy” Remove part of the non-eloquent brain “ Lobectomy”
60. Summary of TBI management Steps Rationale Respiratory support (intubation & ventilation) Comatose, unable to protect airways Elevate head 30-45° Facilitate venous drainage Straighten neck, no tape encircling the neck Facilitate venous drainage Avoid hypotension (SBP<90mmHg) Prevent hypoxia – edema Control hypertension Avoid transmission of pressure to ICP Avoid hypoxia (PaCO2 < 60mmHg) Prevent vasodilatation Control ventilation, aims PaCO2 35-40 mmHg Avoid vasoconstriction / -dilatation Adequate sedation To reduce brain metabolism Do CT brain Ascertain intracranial pathology rapidly
