Management of traumatic brain injury

Review course 2014
Dr.Anand.M.Tiwari
IDCC,F.N.B Critical care medicine
anand tiwari reveiw course 2014

 377 deaths daily.
 1356 –injury
 Yr 2012—1,38,245 death
 Yr 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.
(Contracou
p Injury)

 Diffuse axonal injury
24% mortality
 Focal lesion
39% mortality

 Hypoxia
 Hypotension
 Hypocapnia Remember H Effect
 Hypercapnia
 Hyperthermia
 Hypoglycemia
 Hyperglycemia
 Hypernatremia
 Hyponatremia
 Hyperosmolarity
 infections

Review of 25 studies
HEMS showed survival benefit in some
Which 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*
Sedation
intubation

Field cervical spine clearance is
not 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

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.

 Definite role in defining shear injuries and
for prediction of prognosis

 F
 A
 S
 T
 H
 U
 G
Give your patient a fast hug (at least) once a day.
Vincent JL.

 Crystalloids NS,RL
 Colloids
 Blood transfusion Trigger
 Use of vasopressor- Dopamine/noradrenaline

 Feeding ASAP ,<24 HRS
 Hyper catabolic
 NG feed ? Orogastric tube Enteral route
 Can consider prokinetic
 PEG long term
Perel P, Yanagawa T, Bunn F, Roberts IG, Wentz R. Nutritional support for head-injur
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

Neuroassesment
Sedation vacation

 Risk group- prolong sedation/extracranial
injuries
 Anticoagulant/LMWH___-????
 Look for –illeo femoral
 Graduated TED stockings/pneumatic calf
compressor unproven reasonable alternative

 Head in neutral position
 Venous drainage
 No compression of neck veins by tube tie

 GCS charting frequently
 Daily fast hug
 Hemodynamic monitoring
 Fluid balance
 BBB care
 Brain specific monitoring
 Neurosurgical 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 factors
 Site specific ,bbb penetration
 Other factors

 Which mode?
 No permissive hypercapnia
 Peep ???
 Weaning—
 Off ventilator does not mean extubation
Hyperventilation

 Euglycemia =<150mg% favarouable
 Na Disturbances- SIADH
CSW syndrome
Diabetes insipidus
Core temp-- Normal

 CPP= MAP-ICP
 70……BTF initial adoption*aggressive
fluid/vasopressor..pulmonary complications
 …60

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 decompression
 CSF drainage
 Decompressive craniectomy
 Osmotherapy
 Hyperventilation
 Hypotheramia
 Barbiturate coma
 Steroids
 Cerebral vasospasm-nimodipine
 Seizure 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 drainage
 Reconsider treatment.

 Refractory cases
 Decrease CMRO2/
 Problem hypotension
 remember pearl harbor incident
 Aim till burst suppression on EEG
 Gradual taper –delayed awakening
,predispose patient to nosocomial infection

Awaits
RESCUEicp
results

 reduces all cause mortality***
 May be beneficial in improving neurological
outcomes
if cooling maintained for 48 hrs.

EUROTHERM3235
Recruitment
321 patients have now been recruited to
the trial. Thank you for continuing to enrol!

 HBOT
Stem cell transplant

 Thank you

Management of traumatic brain injury

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