Role of the Critical Care Surgeon in Traumatic Brain

InjuryJon C. Krook, M.D., F.A.C.S.

Department of SurgeryHCMC

Case Presentation #1• 55 y.o. female, MCA at highway speeds

with no helmet– Was cut off by an auto and “laid” the bike

down, was thrown from the bike– Was initially awake and talking to the first

responders but became confused– 10-15 minutes later L pupil became fixed

and dilated– Intubated and transported to HCMC

Admission CT

Post-operative CT

Post-operative CT #2

Case Presentation #2• 23 y.o. in the Air Force, suffered an

accidental GSW to the left side of the head

• Initially managed at another hospital and then transferred to HCMC

Outside Hospital CT

Outside Hospital CT PID#1

HCMC Arrival CT

Initial assessment

Initial evaluation of the Brain Injured Patient

• ATLS primary and secondary survey

• Avoid hypoxia and hypotension– Need to prioritize injury management

ATLS Primary Survey

A AirwayB BreathingC CirculationD DisabilityE Exposure

Initial evaluation of the Brain Injured Patient

• ATLS primary and secondary survey– A - Intubate if GCS < 8 or other

indication– B - Rule out injury– C - Evaluation/Treatment of shock– D- Evaluation of mental status– E- Look for other injuries

– Secondary survey- comprehensive physical exam

Initial evaluation of the Brain Injured Patient

• Imaging– Chest, pelvic, +/- c-spine x-rays– FAST exam– Head CT

• + LOC• Altered mental status on evaluation

• Surgery– Head or other

• Prioritization

General critical care concepts specific to the head injured

patient

Critical Care Evaluation• All early management of the head

injured patient is aimed toward limiting secondary brain injury

• Avoid hypotension or hypoxia

• Preserve oxygen delivery to the uninjured brain

Monro/Kellie Doctrine

Brain

Blood

CSF

Herniation• Supertentorial Herniation

– 1 Uncal (transtentorial)– 2 Central– 3 Cingulate (subfalcine)– 4 Transcalvarial

• Infratentorial– 5 Upward (upward

cerebellar)– 6 Tonsilar (downward

cerebellar)

http://en.wikipedia.org/wiki/Brain_herniation

Intracranial Pressure Monitoring

• Types– Bolt (subdural screw)– Epidural sensor– Ventriculostomy

• Diagnostic• Therapeutic

Cerebral Perfusion Pressure

CCP= MAP - ICP

Preserving MAP• Can be challenging in the face of other

injuries– Shock

• Hypovolemic/hemorrhagic• Cardiogenic• Neurologic

• Vasopressors– Can have downsides

• May increase driving pressure, but may decrease overall blood flow to the brain

Lowering ICP• Options

– Sedation– Draining CSF– Hyperosmolar therapy

Triangle of ICU Sedation

Analgesia

Anxiolytics/Sedation Paralytics

Delirium

Sedation• Propofol

– Rapid onset, short duration of action• Important in awaking trials

– Depresses cerebral metabolism– Reduces cerebral oxygen consumption– Possibly reduces ICPs through direct

methods

Sedation• Fentanyl

– Rapid onset, short duration of action– Usually given as a drip

• Some evidence of worsening of CCP (BP, ICP) with bolus

Hyperosmolar Therapy• Mannitol

– Osmotic diuretic – Can cause hypotension– Fairly quick onset

• Hypertonic saline– Osmotic diuretic– Does not cause hypotension– May increase CPP

Phenobarbital Coma• Not done anymore at HCMC

– Supplanted by iatrogenic hypothermia• Requires intensive monitoring• Downsides to Phenobarbital

– Pneumonia– Feeding intolerance– Cardiac depression

• Hypotension from phenobarbital erases any beneficial effect

Hypothermia• Current practice at HCMC• Better outcomes in most RCTs

examining hypothermia– Mixed results regarding mortality

• None showing worse mortality• Some showing improved mortality

– All RCTs report improved GOS (Glasgow Outcome Scale) in those treated with hypothermia

Decompressive crainectomy• Neurosurgical decision• Violates the Monro-Kellie Doctrine

Anti-Seizure Prophylaxis • Post Traumatic Seizures (PTS)

– Early < 7 days– Late > 7 days

• No evidence that routine prophylaxis decreases late seizures

• Anti-seizure prophylaxis effective in early seizures

Anti-Seizure Prophylaxis • Indications for treatment

– GCS < 10– Cortical contusion– Depressed skull fracture– Subdural hematoma– Intracerebral hematoma– Penetrating head wound– Seizure within 24 h of injury

Steroids

• Only level I data from the Brain Trauma Foundation Guidelines is don’t use

steroids

General Critical Care Concepts

Ventilatory Management• Most significant head injuries get intubated at

some point for airway protection• Some are on significant sedation to impact

their ICP• Most weaning protocols end with the

assessment of the patient’s ability to follow commands

• Therefore many are on ventilators for some time

Ventilatory Management• Most head injured patients have normal

lungs– They don’t all stay that way

Ventilatory Management

Infection prevention/treatment• VAP prevention• Catheter infection prevention• Urinary catheter infection prevention• Fever work ups

– Five W’s• Wind• Water• Wounds• Walking• Wonder Drugs

Nutrition

VTE Prophylaxis • VTE= VenoThromboEmbolism• Risk of developing DVT in severe brain

injury about 20%• Best treatment is prevention• No good data on timing

– DEEP study out of Parkland• IVC Filters

Other conditions• Head injured patients are already

complicated– Adding other injuries adds to the

complexity• Gatekeeper

Ethics• Family discussions• Difficult to predict level of long term

impairment sometimes• There can be fates worse than death• Comfort Care

Case Presentation #1• Fixed and dilated pupils• + Corneals and gag reflexes• Withdraws upper extremities, flexion

posturing lower extremities• Intensive family discussions• Comfort care

Case Presentation #2• Localized to pain on arrival• Ventriculostomy placed• ICPs high

– All efforts employed including cooling• Cooled for about a week

• Neurologic exam worsened on warming on HD#17

Case Presentation #2

Case Presentation #2

Conclusions• The Trauma Surgeon/Surgical

Intensivist plays a core role in the care of the acute brain injured patient

Questions?