Acute Management of Traumatic Brain Injury

8/8/2019 Acute Management of Traumatic Brain Injury

http://slidepdf.com/reader/full/acute-management-of-traumatic-brain-injury 1/32

Acute Management of Acute Management of

Traumatic Brain InjuryTraumatic Brain InjuryDr N. VairavanDr N. Vairavan

Neurosurgery Unit Neurosurgery UnitDepartment of SurgeryDepartment of Surgery

Faculty of MedicineFaculty of Medicine

University MalayaUniversity Malaya



Traumatic Brain InjuryTraumatic Brain Injury

2% of population/year 2% of population/year 43,000 people/yr 43,000 people/yr

1010 ± ± 15 % severe injury15 % severe injury

65% of mortality due to severe TBI65% of mortality due to severe TBI

Major cause of death and disability amongMajor cause of death and disability among

productive age group productive age group

Major socioeconomic effect on the family,Major socioeconomic effect on the family,

society and countrysociety and country



Prehospital ManagementPrehospital Management

Transport direct to nearest facility with theTransport direct to nearest facility with theresources to intervene and optimise ptresources to intervene and optimise pt

AirwayAirway

BreathingBreathing

CirculationCirculation

Cervical Spine ImmobilisationCervical Spine Immobilisation

Supplemental Oxygen/ Endotracheal intubationSupplemental Oxygen/ Endotracheal intubation Level III evidence of improved survivalLevel III evidence of improved survival

Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survivalin patients with severe head injury. Arch Surgery 132: 592- 597, 1997



Prehospital hypotension (SBP <90), hypoxemiaPrehospital hypotension (SBP <90), hypoxemia(SpO2< 90 )(SpO2< 90 )

± ± independent predictors of outcomeindependent predictors of outcome

Prehospital measurement of GCS, pupillary response-- predictors of outcomepredictors of outcome

Chestnut RM. Role of secondary brain injury in determining outcome in severehead injury. J Trauma. 34: 216 ± 222, 1993

Baxt WG. Impact of advanced prehospital emergency care on the mortality of

severely brain injure patients. J Trauma. 27:365 -369, 1987



Prehospital Brain targeted therapyPrehospital Brain targeted therapy

HyperventilationHyperventilation

MannitolMannitol

SedationSedation

AnalgesicAnalgesic ParalyticParalytic

Only hyperventilation recommended on Level IIIOnly hyperventilation recommended on Level IIIevidence in presence of brain herniationevidence in presence of brain herniation

Raichle M. Hyperventilation and cerebral blood flow. Stroke 3:965Raichle M. Hyperventilation and cerebral blood flow. Stroke 3:965 ± ± 972, 1972972, 1972



Imaging GuidelinesImaging GuidelinesBrainBrain



Imaging GuidelinesImaging Guidelines

Cervical SpineCervical Spine



Hypotension & HypoxemiaHypotension & Hypoxemia

Morbidity & Mortality Morbidity & Mortality

Single episode of SBP < 90 mmHgSingle episode of SBP < 90 mmHg

Apneic cyanosis or SpOApneic cyanosis or SpO22 < 90 or PaO< 90 or PaO22 < 60< 60

Level III evidence onlyLevel III evidence only Miller et al ¶78, Chestnut et al ¶93, Manley et al ¶01, Struchen et al µ01Miller et al ¶78, Chestnut et al ¶93, Manley et al ¶01, Struchen et al µ01

?? Treatment threshold, Optimal resuscitation?? Treatment threshold, Optimal resuscitation

protocals, Target values, treatment impact on protocals, Target values, treatment impact on

outcomeoutcome



Hyperosmolar TherapyHyperosmolar Therapy

Mannitol 0.25 to 1 gm/kg BWMannitol 0.25 to 1 gm/kg BW Single shotSingle shot ± ± buy time for diagnostic or interventional buy time for diagnostic or interventional

procedure procedure ± ± Level III recommendationLevel III recommendation

Prolonged therapyProlonged therapy ± ± for control of persistently raisedfor control of persistently raised

ICPICP Arterial hypotension should be avoidedArterial hypotension should be avoided

??Infusion vs bolus, Risks of prolonged??Infusion vs bolus, Risks of prolonged

administrationadministration

Becker and Vries ¶72, Mendelow et al ¶85, Eisenberg et al ¶88Becker and Vries ¶72, Mendelow et al ¶85, Eisenberg et al ¶88

Roberts I et al Cochrane Syst RV 2003Roberts I et al Cochrane Syst RV 2003



Hyperosmolar TherapyHyperosmolar Therapy

Hypertonic SalineHypertonic Saline

Reduce ICP without compromising BP, CPP or causingReduce ICP without compromising BP, CPP or causing

cerebral vasoconstrictioncerebral vasoconstriction

Osmotic mobilisation, microcirculatory effect, reducedOsmotic mobilisation, microcirculatory effect, reducedleukocyte adhesionleukocyte adhesion

3% saline 0.1 to 1.0mL/kg BW/ Hr on a sliding scale3% saline 0.1 to 1.0mL/kg BW/ Hr on a sliding scale

Level III recommendationLevel III recommendation

HS bolus infusionHS bolus infusion -- effective adjuvant / alternative toeffective adjuvant / alternative to

mannitolmannitol

??Dose, concentration, method??Dose, concentration, method Shackford et al ¶98, Quereshi et al µ99Shackford et al ¶98, Quereshi et al µ99



ProphylacticHypothermiaProphylacticHypothermia Target cooling 32Target cooling 32 --3333ºCºC

Duration of 48HDuration of 48H

Rate of rewarming 1ºC /H or slower Rate of rewarming 1ºC /H or slower

Meta Analysis of 6 RCTMeta Analysis of 6 RCT All cause mortality not different from control groupAll cause mortality not different from control group

46% increased chance of good outcome (GOS 4 or 5)46% increased chance of good outcome (GOS 4 or 5)

Avoid HyperthermiaAvoid Hyperthermia

??Target, duration??Target, duration Abiki et al 2000, Jiang et al 2000, Qiu et al 2003Abiki et al 2000, Jiang et al 2000, Qiu et al 2003



Infection ProphylaxisInfection Prophylaxis Periprocedural antibiotics for intubationPeriprocedural antibiotics for intubation

No change in LOS or mortality (1) No change in LOS or mortality (1)

Early tracheostomyEarly tracheostomy Reduce mechanical ventilation daysReduce mechanical ventilation days

No change in mortality or nosocomial pneumonia rates (2) No change in mortality or nosocomial pneumonia rates (2)

No support for routine catheter changes to prevent No support for routine catheter changes to preventinfection (Linfection (L--III) (3)III) (3)

No support for routine systemic prophylaxis in No support for routine systemic prophylaxis inventilatedTBI patients (LventilatedTBI patients (L--III)III)

Periprocedural prophylaxis does decrease pneumoniaPeriprocedural prophylaxis does decrease pneumonia(L(L--III)III)

1.Poon et al Acta Neur 1998, 2. Sugerman RJ J Trauma 1997, 3. Holloway1.Poon et al Acta Neur 1998, 2. Sugerman RJ J Trauma 1997, 3. Hollowayet al J Neuro 2000,et al J Neuro 2000,



DVT ProphylaxisDVT Prophylaxis 20% pt with TBI develop DVT20% pt with TBI develop DVT

0.38% incidence of PE in TBI pt0.38% incidence of PE in TBI pt

Graduated compression stockings (LGraduated compression stockings (L--III) (1)III) (1)

LMWH used in combination with mechanical prophylaxis (LLMWH used in combination with mechanical prophylaxis (L± ± III) (2)III) (2)

Lower risk of DVT, no difference in mortalityLower risk of DVT, no difference in mortality

Risk of intracranial h¶ghe expansionRisk of intracranial h¶ghe expansion

?? Dose, agent, timing of prophylaxis?? Dose, agent, timing of prophylaxis

1. Black et al Neuro 1986, 2. Gerlach et al Neuro 20031. Black et al Neuro 1986, 2. Gerlach et al Neuro 2003



Indication for ICP MonitoringIndication for ICP Monitoring

ICP in all pt with severe TBI ( GCS 3ICP in all pt with severe TBI ( GCS 3--8) and8) andabnormal CT scan (Labnormal CT scan (L--II)II)

ICP in severe TBI and normal CT scan if ICP in severe TBI and normal CT scan if >40 yrs age>40 yrs age

Unilat or bilat posturingUnilat or bilat posturing SBP < 90mmHgSBP < 90mmHg

ICP monitoring allowsICP monitoring allows Prediction of outcome and worsening intracranial pathologyPrediction of outcome and worsening intracranial pathology

Calculate and manage CPPCalculate and manage CPP

Allow therapeutic CSF drainage in ventricular monitorsAllow therapeutic CSF drainage in ventricular monitors Restrict potentially delterious ICP reduction therapiesRestrict potentially delterious ICP reduction therapies

NarayanRK et al J Neuro 1982 NarayanRK et al J Neuro 1982



ICP Monitoring TechnologyICP Monitoring Technology

Ventricular catheter + ext strain gaugeVentricular catheter + ext strain gauge Parenchymal ICP monitor Parenchymal ICP monitor

Subarachnoid, subdural, epidural monitorsSubarachnoid, subdural, epidural monitors

Pressure range 0Pressure range 0 --100 mmHg100 mmHg

AccuracyAccuracy 2mm Hg in 02mm Hg in 0--20 range20 range

Max error 100% in 20Max error 100% in 20 100 range100 range

ComplicationComplication Hemorhage, Malfunction,Hemorhage, Malfunction,

InfectionInfection

Lundberg et al Acta Psych 1960, Narayan R et al JLundberg et al Acta Psych 1960, Narayan R et al J

Neurosurg 1982, Stendel R et al Acta Neur 2003 Neurosurg 1982, Stendel R et al Acta Neur 2003



ICP ThresholdICP Threshold

Treatment should be commenced at ICP > 20 mmHgTreatment should be commenced at ICP > 20 mmHg(L(L± ±II) (1)II) (1)

Treatment threshold > 25 without craniectomy and >Treatment threshold > 25 without craniectomy and >

15 post craniectomy ( L15 post craniectomy ( L--II) (2)II) (2)

?? Herniation threshold pressure?? Herniation threshold pressure As little as 18mmHgAs little as 18mmHg

?? ICP interaction with CPP, CBF, Sjo2?? ICP interaction with CPP, CBF, Sjo2

1. Marmarou et al J Neuro 1991, 2. Eisenberg et al J Neuro 19881. Marmarou et al J Neuro 1991, 2. Eisenberg et al J Neuro 1988



Brain Oxygen Monitoring andBrain Oxygen Monitoring and

ThresholdThreshold

Jugular venous saturation or brain tissue oxygenJugular venous saturation or brain tissue oxygen

monitoring measure cerebral oxygenationmonitoring measure cerebral oxygenation

SjOSjO22 < 50% (1), P< 50% (1), P br br OO22 < 15mmHg (2) are threshold for < 15mmHg (2) are threshold for

interventionintervention

Cerebral microdialysis, thermal diffusion probe, transcranialCerebral microdialysis, thermal diffusion probe, transcranial

doppler, near infrared spectroscopydoppler, near infrared spectroscopy

1. Robertson CS et al J Neurotrauma 1995 2. Valadka et al 19981. Robertson CS et al J Neurotrauma 1995 2. Valadka et al 1998



BarbituratesBarbiturates

BarbituratesBarbiturates Cerebral protective alteration in vascular tone and resistanceCerebral protective alteration in vascular tone and resistance

Suppression of metabolismSuppression of metabolism

Inhibition of lipid peroxidationInhibition of lipid peroxidation

Inhibition of excitotoxicityInhibition of excitotoxicity

Prophylactic barbiturate to induce burst suppression notProphylactic barbiturate to induce burst suppression notrecommended (1)recommended (1)

High dose barbiturate recommended to control elevated ICPHigh dose barbiturate recommended to control elevated ICPrefractory to standard medical and surgical treatment (2)refractory to standard medical and surgical treatment (2)

Cochrane Systematic Review (2004)Cochrane Systematic Review (2004)µNo evidence that barbiturate therapy in patients with acute severe headµNo evidence that barbiturate therapy in patients with acute severe headinjury improves outcome¶injury improves outcome¶

1. Ward JD et al J Neuro 1985, 2.Eisenberg HM et al J Neuro 1988,1. Ward JD et al J Neuro 1985, 2.Eisenberg HM et al J Neuro 1988,3.Robert I et al. Cochrane Library 20053.Robert I et al. Cochrane Library 2005



NutritionNutrition

Patients should be fed to attain full caloricPatients should be fed to attain full caloricreplacement by day 7 post injury (1)replacement by day 7 post injury (1)

Start gastric or jejunal feed by day 3Start gastric or jejunal feed by day 3

Hyperglycemia should be controlled (2)Hyperglycemia should be controlled (2)

Zinc supplementation may be beneficial (3)Zinc supplementation may be beneficial (3)

1. Taylor SJ et al Crit Care Med.1999, 2. Lam AM et al J Neuro 1991,1. Taylor SJ et al Crit Care Med.1999, 2. Lam AM et al J Neuro 1991,3.Young B et al J Neurotrauma 19963.Young B et al J Neurotrauma 1996



Anti Seizure ProphylaxisAnti Seizure Prophylaxis

Prophylactic anticonvulsants are notProphylactic anticonvulsants are notrecommended for preventing laterecommended for preventing late

posttraumatic seizures (1) posttraumatic seizures (1)

Anticonvulsants are indicated to decreaseAnticonvulsants are indicated to decrease

incidence of early PTS (2)incidence of early PTS (2)

?? Benefit vs compication?? Benefit vs compication

1. Manaka S et al J Psych Neur 1992, 2. Temkin N et al N Eng J Med 19901. Manaka S et al J Psych Neur 1992, 2. Temkin N et al N Eng J Med 1990



HyperventilationHyperventilation

Prophylactic hyperventilation ( PaCO2 < 25) isProphylactic hyperventilation ( PaCO2 < 25) isnot recommended (1)not recommended (1)

Hyperventilation may be used as a temporizingHyperventilation may be used as a temporizingmeasure to reduce ICP (1)measure to reduce ICP (1)

Hyperventilation should be avoided in first 24Hyperventilation should be avoided in first 24hrs of injury (3)hrs of injury (3)

1. Muizellar JP J Neuro 1991, 2. 3. Bouma GJ J Neuro 19921. Muizellar JP J Neuro 1991, 2. 3. Bouma GJ J Neuro 1992



SteroidsSteroids

Steroids is not recommended for improvingSteroids is not recommended for improvingoutcome or reducing ICP (1)outcome or reducing ICP (1)

In moderate to severe TBI, high dose methylIn moderate to severe TBI, high dose methyl

pred is assoc with increased mortality (2) pred is assoc with increased mortality (2)

1. Alderson P Br Med J 1997, 2. Roberts I MRC CRASH Trial Lancet1. Alderson P Br Med J 1997, 2. Roberts I MRC CRASH Trial Lancet20042004



Decompressive CraniectomyDecompressive Craniectomy

Removal of a large portion of skull to provideRemoval of a large portion of skull to provide

spacefor brain expansionspacefor brain expansion

Reduction of refractory ICP due to severe TBIReduction of refractory ICP due to severe TBI

or malignant MCA infarctor malignant MCA infarct Observational studies provide LObservational studies provide L--III evidenceIII evidence

of good outcome (1,2)of good outcome (1,2)

On going LOn going L--I trialsmay provide answers (3,4)I trialsmay provide answers (3,4)

1. Kunze E et al Acta Neuro 1998, 2. Polin RS Neurosurg 1997,1. Kunze E et al Acta Neuro 1998, 2. Polin RS Neurosurg 1997,

3.Hutchinson PJ R ESCUEicp trial, 4. Cooper DJ et al DECRA trial3.Hutchinson PJ R ESCUEicp trial, 4. Cooper DJ et al DECRA trial



GCS<8

CT Brain

Insert ICP Monitor

Maintain CPP

(Age Appropriate)

oICP

Sedation & Analgesia

Head up 300

oICP

Drain CSF if Ventriculostomy

is present

oICP

Neuromuscular Blockade

oICPMannitol PRN HTS 3%

Mild Hyperventilation PaCO2 30-35 mm Hg

May continue if S. Osm<360May continue if

S. Osm<320

oICP

Second Tier

Therapy

Consider CTCarefully withdraw

ICP treatment

NO

NO

NO

NO



Second Tier TherapySecond Tier Therapy

o ICP despite first tier Rx

Evidence of Hyperemia ?Evidence of Hyperemia ?

No Evidence of IschemiaNo Evidence of Ischemia

Consider HyperventilationConsider Hyperventilation

To PaCO2 < 30 mm HgTo PaCO2 < 30 mm Hg

Consider monitoring CBF,Consider monitoring CBF,SjO2, AFDO2SjO2, AFDO2

Evidence of Ischemia?Evidence of Ischemia?

No evidence of No evidence of

contraindicationcontraindication

to Hypothermia?to Hypothermia?

Consider moderateConsider moderate

hypothermiahypothermia

Working VentriculostomyWorking Ventriculostomy

Consider lumbar drainConsider lumbar drain

Active EEG?

No contraindication to

Barb

Consider high dose BarbConsider high dose BarbSalvageable patientSalvageable patient

Consider decompressiveConsider decompressive

craniectomycraniectomy



Thank YouThank You

for for

your kind attention your kind attention

Acute Management of Traumatic Brain Injury

Documents

Transcript of Acute Management of Traumatic Brain Injury