Acute Management ofAcute Management ofTraumatic Brain Injury Traumatic Brain Injury Dr N. Vairavan Dr N. Vairavan Neurosurgery Unit Neurosurgery Unit Department of Surgery Department of Surgery Faculty of Medicine Faculty of Medicine University Malaya University Malaya
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
8/8/2019 Acute Management of Traumatic Brain Injury
Transport direct to nearest facility with theTransport direct to nearest facility with theresources to intervene and optimise ptresources to intervene and optimise pt
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
8/8/2019 Acute Management of Traumatic Brain Injury
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
8/8/2019 Acute Management of Traumatic Brain Injury
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
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
8/8/2019 Acute Management of Traumatic Brain Injury
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,
8/8/2019 Acute Management of Traumatic Brain Injury
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
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
8/8/2019 Acute Management of Traumatic Brain Injury
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
8/8/2019 Acute Management of Traumatic Brain Injury