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คณะพยาบาลศาสตร ์มหาวิทยาลัยมหิดล

Critical care to

Head-Injured Patient

Brain tissue injury

Inflammatory & cerebral edema

Brain tissue

hypoxia CBF ICP vasodilation

Cell death

Necrotic

tissue

edema

Vasodilation ICP from

Blood volume

Further

ICP

Herniation &

compress

brain stem

Accumulate

CO2

Death

CBF

24-48 hours after injury,

CBF to base line

The brain is already swollen

Cause exacerbate neuronal injury

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Severe TBI (GCS = 3-8)

obtain CT brain

secondary insult; hypotension, hypoxia

1survey &

resuscitation

Assess GCS, pupil,

motor response

Monitor : V/S, N/S, GCS

Re-assess

Airway & breathing

Assisting in ET intubation

Monitoring blood gas

Monitoring O2 sat

Circulation

Volume replacement

Assisting in FAST, DPL

IV fluid

Monitor : V/S, LOC

Neurological

examination

2survey &

management

Assess GCS, pupil

reaction, lateralization,

Assess herniation

Repeated CT scan

Assisting in diagnostic

test, surgical treatment

Record & repot

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Initial brain resuscitation

ABCs

secure airway

guarantee gas exchange

stabilize circulation

ICP management protocols

Prevent hypoxia, hypotension

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Nursing management

• cranial blood or CSF volume

• Osmotic diuretics

• Systemic diuretics

• Monitor electrolytes, urine output

• Medication: dexamethasone, histamine

• Posture position

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CPP = MAP - ICP

CPP = 70 - 100 mmHg

MAP = 50 - 150 mmHg

ICP = 5 - 20 mmHg

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The postoperative patients in the

first 24 hours CBF 50%

Head-injured patient after surgery:

CPP should be kept 70 mmHg

MAP should be kept 80-90 mmHg

(Moppett, 2007)

Classic signs of ICP

“Cushing’s triad”

• SBP

• Widening PP

• Bradycardia with a full bounding pulse

• Rapid or irregular respiration

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Late signs of ICP

• Restlessness, then apparent calm

• Deeping stupor and LOC

• Headache and intensity

• Projectile vomiting

• Unequal size of pupils, abnormal reaction

• Widening PP, slow bound pulse

Score for comatose patient

Glasgow Coma Score

(GCS) : 15 points

• Eye response

• Motor response

• Verbal response

Full Outline of

UnResponsiveness

(FOUR) : 16 points

• Eye response

• Motor response

• Brain stem reflexes

• Respiration

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FOUR Scale Glasgow coma scale

Eye response

4 Eyelids open/opened, tracking, or blink to command

3 Eyelids open but with no tracking

2 Eyelids are closed but open to loud voices

1 Eyelids are closed but open to pain

0 Eyelids remain closed with pain

Eye opening

4 Spontaneous eye opening

3 Eye opening to speech

2 Eye opening to pain

1 No reaction to pain

Motor response

4 Thumb –up, fist, or peace sign

3 Localized pain

2 Flexion response to pain

1 Extension response to pain

0 No response to pain or generalized myodonous status

Best motor response

6 Obeying commands

5 Localization to pain

4 Normal flexion to pain

3 Abnormal flexion to pain

2 Extension to pain

1 No response to pain

Brainstem Reflex

4 Pupil and corneal reflexes present

3 One pupil wide and fixed

2 Pupil or corneal reflexes absent

1 Pupil and corneal reflexes absent

0 Absent pupil, corneal, and cough reflex

Best verbal response

5 Oriented

4 Confused conversation

3 Inappropriate words

2 Incomprehensible sounds

1 No response

Respiration

4 Not intubated, regular breathing pattern

3 Not intubated, cheyne-strokes breathing pattern

2 Not intubated, irregular breathing

1 Breathes above ventilator rate

0 Breathes at ventilator rate or apnea

Severity of injuries

Mild

head injury

• GCS = 13-15

• associated with

loss of

consciousness

or amnesia for

less

• than 1 hour

Moderate

head injury

• GCS = 9-12

• associated with

a loss of

consciousness

for up to a day

Severe

head injury

• GCS less than

or equal to 8

• associated with

loss of

consciousness

for more than

24 hours

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FOUR scale 15-16 FOUR scale 8-14 FOUR scale 0-7

1 point Four score

mortality reduce 36%

poor function outcome reduce 29%

poor neurological outcome reduce 33%

Sadaka, et al., 2012

Nursing management

• Adequate oxygenation, perfusion, CPP

• Osmotherapy

• Prepare for surgical intervention

• Pharmacologic agent ; ICP, cerebral edema

• Close monitoring

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Severe TBI (GCS = 3-8)

obtain CT brain

secondary insult; hypotension, hypoxia

1survey &

resuscitation

Assess GCS, pupil,

motor response

Monitor : V/S, N/S, GCS

Re-assess

Airway & breathing

Assisting in ET intubation

Monitoring blood gas

Monitoring O2 sat

Circulation

Volume deplacement

Assisting in FAST, DPL

IV fluid

Monitor : V/S, LOC

Neurological

examination

2survey &

management

Assess GCS, pupil

reaction, lateralization,

Assess herniation

Repeated CT scan

Assisting in diagnostic

test, surgical tratment

Record & repot

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Medication therapy

Intravenous fluids

Maintain volume

Prevent hypovolemia

Should not use hypotonic fluids

Monitor serum Na+ level

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Medication therapy

Hyperventilation

PaCO2

Normocarbia

keep PaCO2 at 35 mmHg

For acute neurologic deterioration;

keep PaCO2 at 25-35 mmHg

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Medication therapy

Mannitol

elevate intracranial pressure

Usually use 20% IV, 1 g/kg

acute neurologic deterioration;

bolus mannitol 1 g/kg rapidly > 5 min,

then CT brain

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Medication therapy

Furosamide

Conjunction use with mannitol

Usually use 0.3-0.5 mg/kg IV

Steroids

Control ICP

Improve severe brain injury

Medication therapy

Barbitulates

ICP

Not indicated in the acute

resuscitative phase

Anticonvulsants

100 mg/8 hours,

1 gm.IV rate < 50mg/min

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SIRS

First hit: Tissue injury

Inadequate resuscitate

Host response:

- Local pro-inflammatory

- Local anti-inflammatory

Uncontrolled

inflammatory response

Shock

Tissue ischemia

/hypoxia

Endothelial

dysfunction

Injury

Primed inflammatory

system

Activation of complement,

coagulation, inflammatory cascades

Tissue

hypoperfusion

Renal dysfunction Hematologic dysfunction

MODS

Urden, et al., 2010; Deitch, Vincent & Windsor, 2002

Organ indicator none minimal mild moderate severe

Respiratory PaO2/FiO2

ratio

> 300 226-300 151-225 76-150 ≤ 75

Renal Serum

creatinine

(umol/L)

≤ 100 101-200 201-350 351-500 > 500

Hepatic Serum

birirubin

(umol/L)

≤ 20 21-60 61-120 121-240 > 240

Cardiovascular CVP/MAP < 10.0 10.1-

15.0

15.1-20.0 20.1-30.0 > 30.0

Hematologic Platelet

count

(mm3)

>

120,000

81,000-

120,000

51,000-

80,000

21,000-

50,000

≤ 20,000

Neurologic GCS 15 13-14 10-12 7-9 ≤ 6

Multiple Organ Dysfunction Score

Marshall,J.C.(2003) ACS Surgery : Principle and Practice

Dysfunction 0 1 2 3

Pulmonary PaO2/FiO2 >208 208-165 165-83 <83

Renal

Creatinine (umol/l)

>159 160-210 211-420 >420

Hepatic

Total Birilubin (umol/l)

<34 34-68 69-137 >137

Cardiac

Inotropes

No inotropes Only one

inotrope at a

small dose

Any inotrope at

moderate dose

or >1 agent,

all at small

dose

Any inotrope at

large dose

or >2 agents,

at moderate

dose

Denver Postinjury

Multiple organ Failure Score (Moore)

• ISS >15, survived longer 48 hr, 16 years of age

Principle emergency care

of critical patient

Adequate oxygenation

Adequate perfusion

Adequate cerebral perfusion

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(A-a)DO2 = PAO2 - PaO2

Oxygen in alveoli = PAO2

Arterial oxygen pressure = PaO2

Alveolar arterial gradient; (A-a)DO2

(A-a) DO2 > 20 mmHg = O2 deficiency (Hennessey & Japp, 2007)

Alveolar arterial gradient; (A-a)DO2

(A-a)DO2 = PAO2 - PaO2

= (713 x FiO2) - PaCO2 /0.85

www.globalrph.com/aagrad.cgi

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Blood glucose

aerobic metabolism ของกลโูคสให้

พลังงาน 38 ATP แต่ถ้า anaerobic

metabolism จะใหพ้ลังงานเพยีง 2 ATP

ท าให ้Na+ เคลือ่นเขา้สู่เซลล์ และ K+

เคลื่อนออกนอกเซลล ์เกิดการบวมน า

ของเซลล ์และ Ca++ เคลือ่นเขา้สูเ่ซลล์

ท าใหเ้ซลล์สูญเสยีหนา้ที่

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Hyperglycemia caused

intracellular osmotic pressure

Glucose > 200 mg/dl

O2 deficiency

Cerebral ischemia, anaerobic metabolism