Critical Care Considerations in Acute Traumatic Brain Injury Patients

Report
Role of the Critical Care
Surgeon in Traumatic Brain
Injury
Jon C. Krook, M.D., F.A.C.S.
Department of Surgery
HCMC
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
ATLS Primary Survey
A
B
C
D
E
Airway
Breathing
Circulation
Disability
Exposure
• Avoid hypoxia and hypotension
– Need to prioritize injury management
Initial evaluation of the Brain
Injured Patient
• ATLS primary and secondary survey
–A–B–C– D– E-
Intubate if GCS < 8 or other
indication
Rule out injury
Evaluation/Treatment of shock
Evaluation of mental status
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
CSF
Blood
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?

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