{"id":5405,"date":"2011-09-06T15:55:35","date_gmt":"2011-09-06T15:55:35","guid":{"rendered":"http:\/\/crashtext.org\/misc\/severe-traumatic-brain-injury.htm\/"},"modified":"2018-02-24T17:43:22","modified_gmt":"2018-02-24T22:43:22","slug":"severe-traumatic-brain-injury","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/trauma\/system\/severe-traumatic-brain-injury.htm\/","title":{"rendered":"Severe Traumatic Brain Injury"},"content":{"rendered":"

Neglected phases of TBI-apneic and catecholamine surge<\/a><\/p>\n

Severe injury=GCS<8<\/span><\/p>\n

Suspect elevated ICP if:<\/p>\n

GCS<8 or<\/p>\n

GCS \u2264 10 and:<\/p>\n

Hematoma volume > 30 ml (A,B,C,\/2)<\/p>\n

Midline Shift > 1 cm<\/p>\n

Pineal shift > 5 mm<\/p>\n

Compression of the Lateral Ventricles<\/p>\n

<\/span>CT Interpretation<\/a><\/span><\/h2>\n

<\/span>New BTF Recs<\/span><\/h2>\n

B. Level II<\/p>\n

Blood pressure should be monitored and hypotension (systolic blood pressure 90 mm Hg) avoided.<\/p>\n

C. Level III<\/p>\n

Oxygenation should be monitored and hypoxia (PaO<\/p>\n

2 60 mm Hg or O2 saturation 90%) avoided.<\/p>\n

B. Level II<\/p>\n

Mannitol is effective for control of raised intracranial pressure (ICP) at doses of 0.25 gm\/kg to 1 g\/kg body weight. Arterial hypotension (systolic blood pressure 90 mm Hg) should be avoided.<\/p>\n

C. Level III<\/p>\n

Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurological deterioration not attributable to extracranial causes.<\/p>\n

C. Level III<\/p>\n

Pooled data indicate that prophylactic hypothermia isnot significantly associated with decreased mortality when compared with normothermic controls. However, preliminary findings suggest that a greater decrease in mortality risk is observed when target temperatures are maintained for more than 48 h. Prophylactic hypothermia is associated with significantly higher Glasgow Outcome Scale (GOS) scores when compared to scores for normothermic controls.<\/p>\n

B. Level II<\/p>\n

Periprocedural antibiotics for intubation should be administered to reduce the incidence of pneumonia. However,<\/p>\n

it does not change length of stay or mortality. Early tracheostomy should be performed to reduce mechanical ventilation days. However, it does not alter mortality or the rate of nosocomial pneumonia.<\/p>\n

C. Level III<\/p>\n

Routine ventricular catheter exchange or prophylactic antibiotic use for ventricular catheter placement is not<\/p>\n

recommended to reduce infection. Early extubation in qualified patients can be done without increased risk of pneumonia.<\/p>\n

C. Level III<\/p>\n

Graduated compression stockings or intermittent pneumatic compression (IPC) stockings are recommended,<\/p>\n

unless lower extremity injuries prevent their use. Use should be continued until patients are ambulatory. Low molecular weight heparin (LMWH) or low dose unfractionated heparin should be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial hemorrhage.<\/p>\n

B. Level II<\/p>\n

Intracranial pressure (ICP) should be monitored in all salvageable patients with a severe traumatic brain injury (TBI; Glasgow Coma Scale [GCS] score of 3\u00968 after resuscitation) and an abnormal computed tomography (CT) scan. An abnormal CT scan of the head is one that reveals<\/p>\n

hematomas, contusions, swelling, herniation, or compressed basal cisterns.<\/p>\n

C. Level III<\/p>\n

ICP monitoring is indicated in patients with severe TBI with a normal CT scan if two or more of the following features are noted at admission:<\/p>\n

age over 40 years,<\/p>\n

unilateral or bilateral motor posturing, or<\/p>\n

systolic blood pressure (BP) 90 mm Hg.<\/p>\n

B. Level II<\/p>\n

Treatment should be initiated with intracranial pressure (ICP) thresholds above 20 mm Hg.<\/p>\n

C. Level III<\/p>\n

A combination of ICP values, and clinical and brain CT findings, should be used to determine the need for treatment.<\/p>\n

B. Level II<\/p>\n

Aggressive attempts to maintain cerebral perfusion pressure (CPP) above 70 mm Hg with fluids and pressors should be avoided because of the risk of adult respiratory distress syndrome (ARDS).<\/p>\n

C. Level III<\/p>\n

CPP of <50 mm Hg should be avoided.<\/p>\n

C. Level III<\/p>\n

Jugular venous saturation (50%) or brain tissue oxygen tension (15 mm Hg) are treatment thresholds. Jugular venous saturation or brain tissue oxygen monitoring measure cerebral oxygenation.<\/p>\n

B. Level II<\/p>\n

Prophylactic administration of barbiturates to induce burst suppression EEG is not recommended.<\/p>\n

High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. Hemodynamic stability is essential before and during barbiturate therapy.<\/p>\n

Propofol is recommended for the control of ICP, but not for improvement in mortality or 6 month outcome. High-dose propofol can produce significant morbidity.<\/p>\n

B. Level II<\/p>\n

Patients should be fed to attain full caloric replacement by day 7 post-injury.<\/p>\n

B. Level II<\/p>\n

Prophylactic use of phenytoin or valproate is not recommended for preventing late posttraumatic seizures (PTS).<\/p>\n

Anticonvulsants are indicated to decrease the incidence of early PTS (within 7 days of injury). However, early PTS is not associated with worse outcomes.<\/p>\n

B. Level II<\/p>\n

Prophylactic hyperventilation (PaCO2 of 25 mm Hg or less) is not recommended.<\/p>\n

C. Level III<\/p>\n

Hyperventilation is recommended as a temporizing measure for the reduction of elevated intracranial pressure (ICP).<\/p>\n

Hyperventilation should be avoided during the first 24 hours after injury when cerebral blood flow (CBF) is often<\/p>\n

critically reduced.<\/p>\n

If hyperventilation is used, jugular venous oxygen saturation (SjO<\/p>\n

2) or brain tissue oxygen tension (PbrO2) measurements are recommended to monitor oxygen delivery.<\/p>\n

A. Level I<\/p>\n

The use of steroids is not recommended for improving outcome or reducing intracranial pressure (ICP). In patients with moderate or severe traumatic brain injury (TBI), high-dose methylprednisolone is associated with increased mortality and is contraindicated.<\/p>\n

<\/span>Guidelines<\/span><\/h2>\n

Guidelines for Management of TBI (Brain Trauma Taskforce, braintrauma.org)<\/p>\n

Not following these guidelines led to poorer outcome (Acta Neurochir 1999;141(11):1203-8)<\/p>\n

<\/span>ED Goals<\/span><\/h2>\n

systolic blood pressure (SBP) > 90 at all times and preferably a SBP = 120 mmHg, MAP > 85 mm Hg, ICP < 20 mm Hg, CPP > 60 mmHG, O2 saturation > 90%, and PaO2 > 60 mm Hg<\/p>\n

Any episode of hypotension or hypoxia dramatically increases head injury mortaility (Archives of Surg 2001:136;1118-1123)<\/p>\n

A single episode of hypotension (BP <90 mmHg) or hypoxia (PaO2 <60 mmHg) during the initial resuscitation was associated with a 150% increase in morbidity and mortality–Chestnut RM. J Trauma 1993; 34:216-222.<\/p>\n

New study shows that hypotensive increases the mortality dramatically, but not more than non-head injured trauma patients (J Trauma 2005;59:830-835)<\/p>\n

<\/span>Injuries<\/span><\/h2>\n

<\/span>Coup Contracoup<\/span><\/h3>\n

brain hits opposite wall first. Air bubble in soda bottle (Neurocritical Care 2004;1:384)<\/p>\n

<\/span>Diffuse Axonal Injury<\/span><\/h3>\n

Widespread structural failure of axons<\/p>\n

<\/span>Who Needs Surgery?<\/span><\/h2>\n

\"\"<\/a><\/p>\n

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A Simple Tool To Predict The Need To Operate On A Subdural Hematoma<\/p>\n