Brain Injury Symposium

Dr. Ignacio J. PreviglianoDr. Ignacio J. Previgliano

Unidad de Terapia IntensivaUnidad de Terapia Intensiva

Hospital Gral. de Agudos J.A. FernándezHospital Gral. de Agudos J.A. Fernández

Brain Injury SymposiumBrain Injury Symposium

Management of Moderate and Severe Management of Moderate and Severe Head InjuriesHead Injuries

IJP´01IJP´01Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD

The European Brain Injury Consortium. The European Brain Injury Consortium. Nemo solus satis sapit: nobody knows Nemo solus satis sapit: nobody knows enough alone.enough alone.Acta Neurochir (Wien). 1997;139(9):797-803Acta Neurochir (Wien). 1997;139(9):797-803

With globalization, goods, capital, culture, With globalization, goods, capital, culture, and knowledge readily diffuse across and knowledge readily diffuse across borders, but political and social borders, but political and social institutions often lag a step behind.institutions often lag a step behind.

Infection and inequalities: The modern plagues. Farmer P (ed). Berkley: Infection and inequalities: The modern plagues. Farmer P (ed). Berkley: Universityof California Press, 1999Universityof California Press, 1999


EpidemiologyEpidemiology

Study designs.Study designs. Developed and developing countries Developed and developing countries

reality.reality. Frontiers between rich and poor in each Frontiers between rich and poor in each

society.society. Urban and rural enviromentUrban and rural enviroment Sanitary organizationSanitary organization


ATLS ProceduresATLS Procedures

A:A: Airway with cervical spine control Airway with cervical spine control

B:B: Breathing Breathing

C:C: Circulation (MAP and capillar refill) Circulation (MAP and capillar refill)

D:D: Neurological deficit (GCS) Neurological deficit (GCS)


GCS GCS (After resuscitation) (After resuscitation)

GCS < 8GCS < 8 GCS > 8GCS > 8

Pupillary Pupillary asimetryasimetry

IsocoriaIsocoria

Intubation Intubation HV HV

Mannitol Mannitol (0.25 a 0.5 (0.25 a 0.5

mg/kg/bolo) mg/kg/bolo) CT ? CT ?

NeurosurgeryNeurosurgery

Intubation Intubation CT CT

ICU ICU NeurosurgeryNeurosurgery

GCS 9 - 13GCS 9 - 13 GCS 14 -15GCS 14 -15

CT CT Intensive - Intensive -

Intermediate Intermediate Care Care

Neurosurgery?Neurosurgery?

Italian Italian Guidelines Guidelines for Minor for Minor

Head InjuryHead Injury


Glasgow 9 - 13

Clinical observation 48 hs, CT and neurosurgical consultation

No intracranial No intracranial lesionlesionNo intracranial No intracranial lesionlesion

Intracranial Intracranial lesionlesionIntracranial Intracranial lesionlesion

New CT in 48 hsNew CT in 48 hsNew CT in 48 hsNew CT in 48 hs TCDB III TCDB III Temporal Temporal Contusion Contusion

TCDB III TCDB III Temporal Temporal Contusion Contusion

TCDB I - II TCDB I - II ContusionContusionTCDB I - II TCDB I - II ContusionContusion

NICU ICPNICU ICPNICU ICPNICU ICP

NINCU NINCU Hourly GCSHourly GCSNINCU NINCU Hourly GCSHourly GCS


Gidelines for the management of Gidelines for the management of severe traumatic brain injury severe traumatic brain injury

Trauma Systems Initial management

Resuscitation of blood pressure and oxygenation Indications for intracranial pressure monitoring Intracranial pressure treatment threshold Recommendations for intracranial pressure monitoring technology Guidelines for cerebral perfusion pressure Hyperventilation

Hyperventilation Use of mannitol Use of barbiturates in the control of intracranial hypertension Rol of steroids Critical pathway for the treatment of established intracranial hypertension Nutrition Rol of antiseizure prophylaxis following head injury


Classification of evidenceClassification of evidenceClass I evidence:Prospective randomized controlled trials , the (Standards)

gold standard of clinical trials. However some may be poorly designed, lack sufficient patientnumbers or suffer from other methodological inadequacies.

Class II evidence: Clinical studies in which the data was (Guidelines)collected prospectively, and retrospective analyses that were based on clearly reliable data (observational, cohort, prevalence and case control studies)

Class III evidence: Most studies based on retrospectively collected (Options)data (clinical series, databases or registries, case reviews, case report) Expert opinion.

Class I evidence:Prospective randomized controlled trials , the (Standards)gold standard of clinical trials. However some may be poorly designed, lack sufficient patientnumbers or suffer from other methodological inadequacies.

Class II evidence: Clinical studies in which the data was (Guidelines)collected prospectively, and retrospective analyses that were based on clearly reliable data (observational, cohort, prevalence and case control studies)

Class III evidence: Most studies based on retrospectively collected (Options)data (clinical series, databases or registries, case reviews, case report) Expert opinion.


Trauma systemsTrauma systemsGuidelines:Guidelines:

All regions should have an organized trauma care systemAll regions should have an organized trauma care system

Options:Options:

Neurosurgeons should have an organized and responsive system of care for patients with Neurosurgeons should have an organized and responsive system of care for patients with neurotrauma. They should initiate neurotrauma care planning, including pre-hospital neurotrauma. They should initiate neurotrauma care planning, including pre-hospital management and triage, direct trauma center transport, maintain appropriate call schedules, management and triage, direct trauma center transport, maintain appropriate call schedules, review trauma care records for quality improvement and participate in trauma education review trauma care records for quality improvement and participate in trauma education programsprograms

Trauma facilities treating neurotrauma must have a neurosurgery service, an in-house trauma Trauma facilities treating neurotrauma must have a neurosurgery service, an in-house trauma surgeon, a continuously staffed and available operating room, intensive care unit and surgeon, a continuously staffed and available operating room, intensive care unit and laboratory. A CT scanner must be immediately available.laboratory. A CT scanner must be immediately available.

In rural or weather-bound communities without a neurosurgeon, a surgeon should be trained to In rural or weather-bound communities without a neurosurgeon, a surgeon should be trained to perform accurate neurological assessment, including training to perform life-saving surgical perform accurate neurological assessment, including training to perform life-saving surgical treatment of an extracerebral hematoma in a deteriorating patient.treatment of an extracerebral hematoma in a deteriorating patient.

Guidelines:Guidelines:

All regions should have an organized trauma care systemAll regions should have an organized trauma care system

Options:Options:

Neurosurgeons should have an organized and responsive system of care for patients with Neurosurgeons should have an organized and responsive system of care for patients with neurotrauma. They should initiate neurotrauma care planning, including pre-hospital neurotrauma. They should initiate neurotrauma care planning, including pre-hospital management and triage, direct trauma center transport, maintain appropriate call schedules, management and triage, direct trauma center transport, maintain appropriate call schedules, review trauma care records for quality improvement and participate in trauma education review trauma care records for quality improvement and participate in trauma education programsprograms

Trauma facilities treating neurotrauma must have a neurosurgery service, an in-house trauma Trauma facilities treating neurotrauma must have a neurosurgery service, an in-house trauma surgeon, a continuously staffed and available operating room, intensive care unit and surgeon, a continuously staffed and available operating room, intensive care unit and laboratory. A CT scanner must be immediately available.laboratory. A CT scanner must be immediately available.

In rural or weather-bound communities without a neurosurgeon, a surgeon should be trained to In rural or weather-bound communities without a neurosurgeon, a surgeon should be trained to perform accurate neurological assessment, including training to perform life-saving surgical perform accurate neurological assessment, including training to perform life-saving surgical treatment of an extracerebral hematoma in a deteriorating patient.treatment of an extracerebral hematoma in a deteriorating patient.


Initial managementInitial management

Severe Head InjurySevere Head Injury

(GCS 8 or less)(GCS 8 or less)

Severe Head InjurySevere Head Injury

(GCS 8 or less)(GCS 8 or less)ATLS ATLS

EvaluationEvaluationATLS ATLS

EvaluationEvaluation

Emergency diagnostic or Emergency diagnostic or therapeutic procedures therapeutic procedures

as indicatedas indicated

Emergency diagnostic or Emergency diagnostic or therapeutic procedures therapeutic procedures

as indicatedas indicated

Intubation Intubation 52 patients52 patients

Ventilation (PCOVentilation (PCO22 ca 35) ca 35)

16 pleural drainages16 pleural drainages

Fluid resuscitation 2228 Fluid resuscitation 2228 ml crystalloids 1350 ml crystalloids 1350 ml colloidsml colloids

OxygenationOxygenation

Sedation Sedation (midazolam 52 patients)(midazolam 52 patients)

Neuromuscular paralysis Neuromuscular paralysis (pancuronion 47 patients)(pancuronion 47 patients)

Intubation Intubation 52 patients52 patients

Ventilation (PCOVentilation (PCO22 ca 35) ca 35)

16 pleural drainages16 pleural drainages

Fluid resuscitation 2228 Fluid resuscitation 2228 ml crystalloids 1350 ml crystalloids 1350 ml colloidsml colloids

OxygenationOxygenation

Sedation Sedation (midazolam 52 patients)(midazolam 52 patients)

Neuromuscular paralysis Neuromuscular paralysis (pancuronion 47 patients)(pancuronion 47 patients)

Hyperventilation (8)Hyperventilation (8)Mannitol (1 g/kg) (7)Mannitol (1 g/kg) (7)Hyperventilation (8)Hyperventilation (8)Mannitol (1 g/kg) (7)Mannitol (1 g/kg) (7)

CT CT 52 patients52 patientsCT CT 52 patients52 patients

NoNoNoNo

Surgery Surgery (20) (20)

Surgery Surgery (20) (20)

YesYesYesYes

ICU ICU ICP monitoring ICP monitoring

49 patients49 patients

ICU ICU ICP monitoring ICP monitoring

49 patients49 patients

YesYesYesYesHerniation? Herniation? Deterioration?Deterioration?

Surgical lesion?Surgical lesion?

Resolution?Resolution?YesYesYesYes


Resuscitation of blood pressure Resuscitation of blood pressure and oxygenationand oxygenation


Hypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaOHypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaO22 < < 90%) must be avoided and scrupulously avoided, if possible, or 90%) must be avoided and scrupulously avoided, if possible, or corrected immediately in severe TBI patients.corrected immediately in severe TBI patients.Options:Options:The MAP should be maintained above 90 mmHg through the infusion The MAP should be maintained above 90 mmHg through the infusion of fluids throughout the patient’s course to attempt to maintain CPP > of fluids throughout the patient’s course to attempt to maintain CPP > 70 mmHg. Patients with GCS < 9 who are unable to maintain their 70 mmHg. Patients with GCS < 9 who are unable to maintain their airway or who remain hypoxemic despite supplemental O2 required airway or who remain hypoxemic despite supplemental O2 required that their AW be secured, preferably by endotraqueal intubation.that their AW be secured, preferably by endotraqueal intubation.


Hypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaOHypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaO22 < < 90%) must be avoided and scrupulously avoided, if possible, or 90%) must be avoided and scrupulously avoided, if possible, or corrected immediately in severe TBI patients.corrected immediately in severe TBI patients.Options:Options:The MAP should be maintained above 90 mmHg through the infusion The MAP should be maintained above 90 mmHg through the infusion of fluids throughout the patient’s course to attempt to maintain CPP > of fluids throughout the patient’s course to attempt to maintain CPP > 70 mmHg. Patients with GCS < 9 who are unable to maintain their 70 mmHg. Patients with GCS < 9 who are unable to maintain their airway or who remain hypoxemic despite supplemental O2 required airway or who remain hypoxemic despite supplemental O2 required that their AW be secured, preferably by endotraqueal intubation.that their AW be secured, preferably by endotraqueal intubation.


Differences in the incidence of hypoxia and hypotension in the Emergency Room, Differences in the incidence of hypoxia and hypotension in the Emergency Room, between 1987 and 1997 (p 0.01).between 1987 and 1997 (p 0.01).

0%5%

10%15%

20%25%

30%35%

40%45%

50%

Hypoxia Hypotension

19871997

Incidence of hypoxia and hypotensionIncidence of hypoxia and hypotension


GOS according to the presence of GOS according to the presence of hypotensionhypotension

0%

10%

20%

30%

40%

50%

60%

70%

80%

Withouthypotension

Inicialhypotension

(30)

Latehypotensión

(117)

Both(39)

GOS 4-5

GOS 3

GOS 1-2

Modified from Chesnut R. Acta Neurochir Suppl Modified from Chesnut R. Acta Neurochir Suppl

1993;59:121.1993;59:121.


0%

10%

20%

30%

40%

50%

60%

70%

80%

GOS 4-5 GOS 2-3 GOS 1

No hypotension

Inicial hypotension inicial

Initial Hypotension and GOSInitial Hypotension and GOS

p 0.008

p 0.29

p 0.01


0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Total (699) Inicial Hypoxia (78) Late hypoxia (161)

GOS 4-5

GOS 2-3

GOS 1

GOS according to the presence of GOS according to the presence of hypoxiahypoxia

Modified from Chesnut R. J Trauma 1993;34:206Modified from Chesnut R. J Trauma 1993;34:206


Indications for intracranial Indications for intracranial pressure monitoringpressure monitoring

Guidelines:Guidelines:Comatose head injury patients (GCS 3-8) with abnormal CT scans should Comatose head injury patients (GCS 3-8) with abnormal CT scans should undergo ICP monitoring. Comatose patients with normal CT scans have a undergo ICP monitoring. Comatose patients with normal CT scans have a much lower incidence of intracranial hypertension unless they have two or much lower incidence of intracranial hypertension unless they have two or more of the following features at admission: age over 40, unilateral or more of the following features at admission: age over 40, unilateral or bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg. bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg. ICP monitoring in patients with a normalICP monitoring in patients with a normalCT scan with two or more of these risk factors is suggested as a guideline.CT scan with two or more of these risk factors is suggested as a guideline.Routine ICP monitoring is not indicated in patients with mild or moderate Routine ICP monitoring is not indicated in patients with mild or moderate head injury. However, it may be undertaken in certain conscious patients head injury. However, it may be undertaken in certain conscious patients with traumatic mass lesions at the discretion of the treating physician.with traumatic mass lesions at the discretion of the treating physician.

Guidelines:Guidelines:Comatose head injury patients (GCS 3-8) with abnormal CT scans should Comatose head injury patients (GCS 3-8) with abnormal CT scans should undergo ICP monitoring. Comatose patients with normal CT scans have a undergo ICP monitoring. Comatose patients with normal CT scans have a much lower incidence of intracranial hypertension unless they have two or much lower incidence of intracranial hypertension unless they have two or more of the following features at admission: age over 40, unilateral or more of the following features at admission: age over 40, unilateral or bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg. bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg. ICP monitoring in patients with a normalICP monitoring in patients with a normalCT scan with two or more of these risk factors is suggested as a guideline.CT scan with two or more of these risk factors is suggested as a guideline.Routine ICP monitoring is not indicated in patients with mild or moderate Routine ICP monitoring is not indicated in patients with mild or moderate head injury. However, it may be undertaken in certain conscious patients head injury. However, it may be undertaken in certain conscious patients with traumatic mass lesions at the discretion of the treating physician.with traumatic mass lesions at the discretion of the treating physician.


Intracranial pressure monitoringIntracranial pressure monitoring

0%10%20%30%40%50%60%70%80%90%

100%

1987 1997

Differences in the use of intracranial pressure monitoring devices Differences in the use of intracranial pressure monitoring devices between 1987 and 1997. between 1987 and 1997.


Intracranial pressure Intracranial pressure treatment thresholdtreatment threshold

GuidelinesGuidelines

An absolute ICP threshold that is uniformly applicable is An absolute ICP threshold that is uniformly applicable is unlikely to exist. Current data, however, support 20-25 unlikely to exist. Current data, however, support 20-25 mm Hg as an upper threshold above which treatment to mm Hg as an upper threshold above which treatment to lower ICP should generally be initiated.lower ICP should generally be initiated.

OptionsOptions

Interpretation and treatment of ICP based on any Interpretation and treatment of ICP based on any threshold should be corroborated by frequent clinical threshold should be corroborated by frequent clinical examination and CPP data.examination and CPP data.


An absolute ICP threshold that is uniformly applicable is An absolute ICP threshold that is uniformly applicable is unlikely to exist. Current data, however, support 20-25 unlikely to exist. Current data, however, support 20-25 mm Hg as an upper threshold above which treatment to mm Hg as an upper threshold above which treatment to lower ICP should generally be initiated.lower ICP should generally be initiated.

OptionsOptions

Interpretation and treatment of ICP based on any Interpretation and treatment of ICP based on any threshold should be corroborated by frequent clinical threshold should be corroborated by frequent clinical examination and CPP data.examination and CPP data.


Recommendations for intracranial Recommendations for intracranial pressure monitoring technologypressure monitoring technology

In patients who require ICP monitoring, a ventricular catheter In patients who require ICP monitoring, a ventricular catheter connected to an external strain gauge transducer or catheter tip connected to an external strain gauge transducer or catheter tip pressure transducer device is the most accurate reliable method of pressure transducer device is the most accurate reliable method of monitoring ICP and enables therapeutic CSF drainage. Clinically monitoring ICP and enables therapeutic CSF drainage. Clinically significant infections or hemorrhage associated with ICP devices significant infections or hemorrhage associated with ICP devices causing patient morbidity are rare and should not deter the decision causing patient morbidity are rare and should not deter the decision to monitor ICP. Parenchymal catheter tip pressure transducer to monitor ICP. Parenchymal catheter tip pressure transducer devices measure ICP similar to ventricular ICP pressure but have devices measure ICP similar to ventricular ICP pressure but have the potential for significant measurement differences and drift due to the potential for significant measurement differences and drift due to the inability to recalibrate. These devices are advantageous when the inability to recalibrate. These devices are advantageous when ventricular ICP is not obtained or if there is obstruction in the fluid ventricular ICP is not obtained or if there is obstruction in the fluid couple. Subarachnoid or subdural fluid coupled devices and epidural couple. Subarachnoid or subdural fluid coupled devices and epidural ICP devices are currently less accurateICP devices are currently less accurate

In patients who require ICP monitoring, a ventricular catheter In patients who require ICP monitoring, a ventricular catheter connected to an external strain gauge transducer or catheter tip connected to an external strain gauge transducer or catheter tip pressure transducer device is the most accurate reliable method of pressure transducer device is the most accurate reliable method of monitoring ICP and enables therapeutic CSF drainage. Clinically monitoring ICP and enables therapeutic CSF drainage. Clinically significant infections or hemorrhage associated with ICP devices significant infections or hemorrhage associated with ICP devices causing patient morbidity are rare and should not deter the decision causing patient morbidity are rare and should not deter the decision to monitor ICP. Parenchymal catheter tip pressure transducer to monitor ICP. Parenchymal catheter tip pressure transducer devices measure ICP similar to ventricular ICP pressure but have devices measure ICP similar to ventricular ICP pressure but have the potential for significant measurement differences and drift due to the potential for significant measurement differences and drift due to the inability to recalibrate. These devices are advantageous when the inability to recalibrate. These devices are advantageous when ventricular ICP is not obtained or if there is obstruction in the fluid ventricular ICP is not obtained or if there is obstruction in the fluid couple. Subarachnoid or subdural fluid coupled devices and epidural couple. Subarachnoid or subdural fluid coupled devices and epidural ICP devices are currently less accurateICP devices are currently less accurate


Guidelines for cerebral Guidelines for cerebral perfusion pressureperfusion pressure

Guidelines for cerebral Guidelines for cerebral perfusion pressureperfusion pressure

Option:Option:Maintenance of a CPP above 70 mm Hg is a therapeutic Maintenance of a CPP above 70 mm Hg is a therapeutic option that may be associated with a substantial reduction option that may be associated with a substantial reduction in mortality and improvement in quality of survival and is in mortality and improvement in quality of survival and is likely to enhance perfusion to ischemic regions of the likely to enhance perfusion to ischemic regions of the brain following severe TBI. No study has demonstrated brain following severe TBI. No study has demonstrated that the incidence of intracranial hypertension, morbidity, that the incidence of intracranial hypertension, morbidity, or mortality is increased by the active maintenance of or mortality is increased by the active maintenance of CPP above 70 mm Hg, even if this means normalizing the CPP above 70 mm Hg, even if this means normalizing the intravascular volume or inducing systemic hypertension intravascular volume or inducing systemic hypertension

Option:Option:Maintenance of a CPP above 70 mm Hg is a therapeutic Maintenance of a CPP above 70 mm Hg is a therapeutic option that may be associated with a substantial reduction option that may be associated with a substantial reduction in mortality and improvement in quality of survival and is in mortality and improvement in quality of survival and is likely to enhance perfusion to ischemic regions of the likely to enhance perfusion to ischemic regions of the brain following severe TBI. No study has demonstrated brain following severe TBI. No study has demonstrated that the incidence of intracranial hypertension, morbidity, that the incidence of intracranial hypertension, morbidity, or mortality is increased by the active maintenance of or mortality is increased by the active maintenance of CPP above 70 mm Hg, even if this means normalizing the CPP above 70 mm Hg, even if this means normalizing the intravascular volume or inducing systemic hypertension intravascular volume or inducing systemic hypertension


CPP and outcomeCPP and outcome

66

68

70

72

74

76

78

80

82

84

GOS 2-5 GOS 1-3 GOS 4-5 GOS 1 GOS 2 GOS 3 GOS 5

Mean CPP

Statistical differences (two tails) for CPP were found for: GOS 2 - 5 against GOS 1 (p Statistical differences (two tails) for CPP were found for: GOS 2 - 5 against GOS 1 (p < 0.01), GOS 4 - 5 against GOS 1 - 3 (p < 0.01), GOS 5 against GOS 3 (p 0.02), GOS 5 < 0.01), GOS 4 - 5 against GOS 1 - 3 (p < 0.01), GOS 5 against GOS 3 (p 0.02), GOS 5 against GOS 2 (p 0.01) and GOS 5 against GOS 1 (p < 0.01).against GOS 2 (p 0.01) and GOS 5 against GOS 1 (p < 0.01).


Effectiveness of raising CPP with Effectiveness of raising CPP with dopaminedopamine

-10

-5

0

5

10

15

20

25

30

35

MAP ICP CPP PtiO2 SjO2

CPP > 60

CPP < 40

*

* p < 0.05

*

*

*

*

*

Modified from Unterberg AW, J Trauma 1997;42Supp:S33Modified from Unterberg AW, J Trauma 1997;42Supp:S33


Effectiveness of head positionEffectiveness of head position

0

1

2

3

4

5

6

7


0º head

*

* p < 0.05

*



HyperventilationHyperventilationStandardStandard

In the absence of increased ICP chronic prolonged HV therapy (PaCOIn the absence of increased ICP chronic prolonged HV therapy (PaCO22 << 25 mmHg) should be avoided after TBI. 25 mmHg) should be avoided after TBI.


The use of prophylactic HV (PaCOThe use of prophylactic HV (PaCO22 << 30 mmHg) during the first 24 hs 30 mmHg) during the first 24 hs after severe TBI should be avoided because it can compromise cerebral after severe TBI should be avoided because it can compromise cerebral perfusion during a time when CBF is reduced.perfusion during a time when CBF is reduced.

OptionsOptionsHV may be necessary for brief periods when there is acute neurological HV may be necessary for brief periods when there is acute neurological deterioration or for longer periods if there is refractory intracranial deterioration or for longer periods if there is refractory intracranial hypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help to hypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help to identify cerebral ischemia if HV is necessary.identify cerebral ischemia if HV is necessary.

StandardStandard

In the absence of increased ICP chronic prolonged HV therapy (PaCOIn the absence of increased ICP chronic prolonged HV therapy (PaCO22 << 25 mmHg) should be avoided after TBI. 25 mmHg) should be avoided after TBI.


The use of prophylactic HV (PaCOThe use of prophylactic HV (PaCO22 << 30 mmHg) during the first 24 hs 30 mmHg) during the first 24 hs after severe TBI should be avoided because it can compromise cerebral after severe TBI should be avoided because it can compromise cerebral perfusion during a time when CBF is reduced.perfusion during a time when CBF is reduced.

OptionsOptionsHV may be necessary for brief periods when there is acute neurological HV may be necessary for brief periods when there is acute neurological deterioration or for longer periods if there is refractory intracranial deterioration or for longer periods if there is refractory intracranial hypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help to hypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help to identify cerebral ischemia if HV is necessary.identify cerebral ischemia if HV is necessary.


The effect of hyperventilationThe effect of hyperventilation

-25

-20

-15

-10

-5

0

5

10

15

20

MAP ICP CPP ETCO2 PtiO2 SjO2

Hyperventilation

*

* p < 0.05

**

*

*



Use of MannitolUse of MannitolGuidelinesGuidelinesMannitol is effective for control of raised ICP after severe TBI. Effective Mannitol is effective for control of raised ICP after severe TBI. Effective doses range from 0.25 to 1 g/kg/body weight.doses range from 0.25 to 1 g/kg/body weight.OptionsOptionsIndications to it use prior to ICP monitoring are signs of transtentorial Indications to it use prior to ICP monitoring are signs of transtentorial herniation or neurological worsening not attributable to extracranial herniation or neurological worsening not attributable to extracranial explanations. Hypovolemia should be avoided by fluid replacement.explanations. Hypovolemia should be avoided by fluid replacement.Serum osmolarity should be kept below 300 mOsm because of concern for Serum osmolarity should be kept below 300 mOsm because of concern for renal failure.renal failure.Euvolemia should be maintained by adequate fluid replacement. A Foley Euvolemia should be maintained by adequate fluid replacement. A Foley catheter is essential in these patients.catheter is essential in these patients.Intermittent boluses may be more effective than continuous infusion.Intermittent boluses may be more effective than continuous infusion.

GuidelinesGuidelinesMannitol is effective for control of raised ICP after severe TBI. Effective Mannitol is effective for control of raised ICP after severe TBI. Effective doses range from 0.25 to 1 g/kg/body weight.doses range from 0.25 to 1 g/kg/body weight.OptionsOptionsIndications to it use prior to ICP monitoring are signs of transtentorial Indications to it use prior to ICP monitoring are signs of transtentorial herniation or neurological worsening not attributable to extracranial herniation or neurological worsening not attributable to extracranial explanations. Hypovolemia should be avoided by fluid replacement.explanations. Hypovolemia should be avoided by fluid replacement.Serum osmolarity should be kept below 300 mOsm because of concern for Serum osmolarity should be kept below 300 mOsm because of concern for renal failure.renal failure.Euvolemia should be maintained by adequate fluid replacement. A Foley Euvolemia should be maintained by adequate fluid replacement. A Foley catheter is essential in these patients.catheter is essential in these patients.Intermittent boluses may be more effective than continuous infusion.Intermittent boluses may be more effective than continuous infusion.


Effectiveness of mannitol 0.5 Effectiveness of mannitol 0.5 g/kg/bolus administrationg/kg/bolus administration

-8-6-4-202468

1012


ICP < 20

ICP > 20


* p < 0.05

SjO2 basal 69%, Pti O2 basal 39 mmHg, SjO2 basal 69%, Pti O2 basal 39 mmHg,

*

*


Use of barbiturates in the control Use of barbiturates in the control of intracranial hypertensionof intracranial hypertension

Guideline:Guideline:

High-dose barbiturate therapy is efficacious in High-dose barbiturate therapy is efficacious in lowering ICP and decreasing mortality in the setting of lowering ICP and decreasing mortality in the setting of uncontrollable ICP refractory to all other conventional uncontrollable ICP refractory to all other conventional medical and surgical ICP-lowering treatments, in medical and surgical ICP-lowering treatments, in salvageable TBI patients. Utilization of barbiturates for salvageable TBI patients. Utilization of barbiturates for the prophylactic treatment of ICP is not indicated. the prophylactic treatment of ICP is not indicated.

Guideline:Guideline:

High-dose barbiturate therapy is efficacious in High-dose barbiturate therapy is efficacious in lowering ICP and decreasing mortality in the setting of lowering ICP and decreasing mortality in the setting of uncontrollable ICP refractory to all other conventional uncontrollable ICP refractory to all other conventional medical and surgical ICP-lowering treatments, in medical and surgical ICP-lowering treatments, in salvageable TBI patients. Utilization of barbiturates for salvageable TBI patients. Utilization of barbiturates for the prophylactic treatment of ICP is not indicated. the prophylactic treatment of ICP is not indicated.


Role of steroidsRole of steroids

Standard:Standard:

The majority of available evidence indicates that The majority of available evidence indicates that steroids do not improve outcome or lower ICP in steroids do not improve outcome or lower ICP in severely head-injured patients. The routine use of severely head-injured patients. The routine use of steroids is not recommended for these purposes.steroids is not recommended for these purposes.

Standard:Standard:

The majority of available evidence indicates that The majority of available evidence indicates that steroids do not improve outcome or lower ICP in steroids do not improve outcome or lower ICP in severely head-injured patients. The routine use of severely head-injured patients. The routine use of steroids is not recommended for these purposes.steroids is not recommended for these purposes.


Use of steroidsUse of steroids

0%

10%

20%

30%

40%

50%

60%

70%

80%

1987 1997

Differences in the use of steroids between 1987 and 1997. This difference was Differences in the use of steroids between 1987 and 1997. This difference was

statistically significant (p > 0.0001) in terms of morbimortalitystatistically significant (p > 0.0001) in terms of morbimortality ..


Monitoring Monitoring (49) (49)

Monitoring Monitoring (49) (49)

CPP > 70 CPP > 70 (52)(52)

CPP > 70 CPP > 70 (52)(52)

ICP > 20ICP > 20

YesYesYesYes

Ventricular drainage (4)Ventricular drainage (4)Ventricular drainage (4)Ventricular drainage (4)

Mannitol 0.5 g/kg/ bolo Mannitol 0.5 g/kg/ bolo (41)(41)

Mannitol 0.5 g/kg/ bolo Mannitol 0.5 g/kg/ bolo (41)(41)

PIC > 20PIC > 20

ICP > 20ICP > 20

PIC > 20PIC > 20

HV PCOHV PCO22 30 - 35 30 - 35

(31)(31)HV PCOHV PCO22 30 - 35 30 - 35

(31)(31)

YesYesYesYes NoNoNoNo

Considerer Considerer repeat CTrepeat CT

Considerer Considerer repeat CTrepeat CT

Cautious Cautious treatment treatment

withdrawalwithdrawal

Cautious Cautious treatment treatment

withdrawalwithdrawal

NoNoNoNo

NoNoNoNoYesYesYesYes

YesYesYesYes

CPP Management CPP Management (22)(22)

CPP Management CPP Management (22)(22)

High dose barbiturates

(4)

High dose barbiturates

(4)

HV PCO2 < 30 Torr HV PCO2 < 30 Torr SjO2 Monitoring (5)SjO2 Monitoring (5)HV PCO2 < 30 Torr HV PCO2 < 30 Torr SjO2 Monitoring (5)SjO2 Monitoring (5)


NutritionNutrition

Guidelines:Guidelines:Replace 140% of resting metabolism expenditure in Replace 140% of resting metabolism expenditure in nonparalyzed patients and 100% in paralized patients nonparalyzed patients and 100% in paralized patients using enteral or parenteral formulas containing at least using enteral or parenteral formulas containing at least 15% of calories as protein by day 7 after injury.15% of calories as protein by day 7 after injury.Options:Options:The preferable option is use of jejunal feeding by The preferable option is use of jejunal feeding by gastrojejunostomy due to ease of use and avoidance of gastrojejunostomy due to ease of use and avoidance of gastric intolerance.gastric intolerance.

Guidelines:Guidelines:Replace 140% of resting metabolism expenditure in Replace 140% of resting metabolism expenditure in nonparalyzed patients and 100% in paralized patients nonparalyzed patients and 100% in paralized patients using enteral or parenteral formulas containing at least using enteral or parenteral formulas containing at least 15% of calories as protein by day 7 after injury.15% of calories as protein by day 7 after injury.Options:Options:The preferable option is use of jejunal feeding by The preferable option is use of jejunal feeding by gastrojejunostomy due to ease of use and avoidance of gastrojejunostomy due to ease of use and avoidance of gastric intolerance.gastric intolerance.


Role of antiseizure prophylaxis Role of antiseizure prophylaxis following head injuryfollowing head injury

Standard:Standard:

Prophylactic use of phenytoin, carbamazepine, phenobarbital or Prophylactic use of phenytoin, carbamazepine, phenobarbital or valproate, is not recommended for preventing late valproate, is not recommended for preventing late posttraumatic seizures. posttraumatic seizures.

Options:Options:

Anticonvulsivants may be used to prevent early PTS in patients Anticonvulsivants may be used to prevent early PTS in patients at risk. This prevention does not indicate an improvement in at risk. This prevention does not indicate an improvement in outcome. outcome.

Standard:Standard:

Prophylactic use of phenytoin, carbamazepine, phenobarbital or Prophylactic use of phenytoin, carbamazepine, phenobarbital or valproate, is not recommended for preventing late valproate, is not recommended for preventing late posttraumatic seizures. posttraumatic seizures.

Options:Options:

Anticonvulsivants may be used to prevent early PTS in patients Anticonvulsivants may be used to prevent early PTS in patients at risk. This prevention does not indicate an improvement in at risk. This prevention does not indicate an improvement in outcome. outcome.


0% 20% 40% 60% 80%

1987

1990

1994

1997

1999

Hospital Fernández, Buenos Aires, Severe Head Injury mortality rates Hospital Fernández, Buenos Aires, Severe Head Injury mortality rates from 1987 to 1999from 1987 to 1999


Brain Injury Symposium

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