Unraveling the Mysteries of Traumatic Brain Injury

Transcription

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2 70% Head Injured Patients Experience a Hypoxic Insult Vitals HR: 50 Blood Pressure: 210/105 Signs of Cushings Triad Hypertension Widening Pulse Pressure Vasomotor Center Bradycardia Cardiac Center Tachypnea Respiratory Center Cushings Response Mannitol administered per the Severe Traumatic Brain Injury Guidelines with a return of bilateral pupillary reflexes With the administration of mannitol her pupillary response returned, and the patient was deemed a surgical candidate. Patient s INR: 2.4 Seven to Ten fold higher risk for development of Intracranial Hemorrhage Increased Risks in Setting of Trauma Increased Morbidity and Mortality Hematoma Expansion Indications INR due to Warfarin Action Hemorrhage judged as acutely life, limb or sight threatening INR >1.5 or clinical evidence the pt is on Warfarin Contraindications Uncontrolled Bleeding Dose 50 international units x Pt wt in Kg Round up/down to nearest full vial Administration Give over 10 minutes Onset of Action 10 minutes Duration of Action 24 hours 2

3 Compatibility Ok to infuse with blood products Mechanism of Action Intrinsic pathway of coagulation cascade Treatment Orders Bebulin x 1 Dose DC Warfarin Vitamin K 10mg IV x 1 dose FFP x 2 Units Adverse Reactions Thrombosis (VTE) Microvascular complications (lung injury, renal failure) How Do I Get the Drug Order form on CHN intranet Phone to pharmacy order is coming Fax order to pharmacy Follow up with pharmacy!!! Send someone to pick up the drug in 20 minutes Cost $ /vial Taken to emergently to the operating room for a right sided decompressive hemicraniectomy Kocher and Cushing first introduced cranial decompression for intracranial hypertension around the turn of the 19 th century Decompression decreases ICP, improves cerebral oxygenation, and improves CBF Timing of Decompression Decompress and evacuate early if there is a lesion causing obvious mass effect Consider your therapeutic intensity when considering timing of decompression SDH with a thickness >10mm or MLS >5mm regardless of GCS ALL patients with a SDH and a GCS <9 should have ICP monitoring GCS <9 with a SDH <10mm in thickness and MLS <5mm should undergo evacuation, if the GCS declines between the time of injury and admit by >2 points and/or the ICP is >20 mm Hg Parenchymal mass lesion and signs of progressive neurologic deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on CT should be treated operatively GCS 6-8 with frontal or temporal contusions >20cc in volume with MLS >5mm and/or cistern compression on CT scan should be treated operatively Any lesion >50cc in volume should be treated operatively 3

4 What Happens in the Operating Room? 15cm 10cm Go Big or Go Home Leave incision open to air Clean surgical site with Normal saline Q12 hours Bacitracin for the first 72 hours Keep patient positioned off surgical wound at ALL TIMES Risk of infection: 6-8% Notify the service ASAP for the following signs of infection Redness or Swelling Drainage Fever Elevated WBC Treatment According to Guidelines Ensure Good Nutrition and Hygiene Practices Daily Showers and Gentle Hair Washing Wound Healing Vitamins Vitamin A, C, Zinc 196 Pages Not Friendly 1 Page!!! User Friendly 4

5 VTE Prophylaxis was Started Options SCDS (Everyone Should Get These!!) Pharmaceutical Anticoagulation Lovenox 40mg SQ QD Heparin 5000units SQ Q8 Timing Patient Dependent The patient was loaded with Dilantin Prophylactic Dosing was Inititiated Who should get prophylaxis? Patient s with GCS <10 Patient s with Parenchymal cotusion(s) SDH EDH depressed skull fracture > skull thickness penetrating head trauma seizure within 24 hours of injury Administer for 7 days unless evidence of seizure activity Therapeutic Levels: 10-20mcg/ml Dilantin (DPH) is highly bound to plasma proteins Albumin (90%) Serum DPH [DPH] = [(0.2 x alb) + 0.1] Side Effects of Dilantin Administration Hypotension, Bradycardia, and EKG Changes Severe Thrombophlebitis (Purple Glove Syndrome CNS depression (nystagmus, somnolence, ataxia *Hypotension (IV) Administer <25mg/min Consider fosphenytoin Skin Necrosis (IV) Use small gauge needle in large vein Avoid IV s in joints Avoid IV s >24 hours old Consider injection of hyaluronidase Hypersensitivity (IV & PO) Rash Blood Dyscrasias (IV & PO) Food Interations (PO) 5

6 Occur in 35% of all TBI patients A single episode of hypotension in TBI leads to a Two-Fold increase in Mortality Post-operative the patient was taken to the ICU and an Intracranial pressure monitor was placed Three episodes of hypotension leads to a Eight-Fold increase in Mortality Hypotentison: Systolic blood pressure <90mmHg ICP Predicts Outcome Why Measure Intracranial Pressure? Beyond age and neuro exam, the amount of time ICP > 20 mm Hg is most predictive of outcome ICP should be monitored in all patients with: severe TBI (GCS 3-8 after resuscitation) AND an abnormal CT scan both on admission and on repeat. 6

7 Patients with severe TBI (GCS 3-8) and a Normal CT scan if 2 or more of the following features are noted upon admission: age > 40 unilateral or bilateral motor posturing SBP < 90 mm Hg A combination of ICP values and clinical and brain CT findings should be used to determine the need for treatment ICP > 20 mm Hg Is it Enough? Case Study: Multimodal Neuromonitoring for TBI CBF EVD P bt O 2 EVD S jv O 2 CBF CVP P bt O 2 7

8 Monitor Placement CBF EVD Licox Complimentary information Local Monitors Brain tissue oxygenation CBF Hemispheric Monitors S jv O 2 P bt O 2 CBF S jv O 2 Stop Secondary Brain Injury!!!! Systemic Insults Hypoxia Hypotension Hyper/Hypocapnia Increase Intracranial Pressure Anemia Hyper/Hypoglycemia Acid base disturbances Early Detection low P a O 2 P bt O 2 Tailor CPP management Optimize Hyperventilation Early Detection of Imminent ICP Elevation By POD#4 all the patient s monitors were able to be discontinued and she was successfully transferred to the floor CBF Brain Tissue Oxygen 8

9 No monitoring available Emphasis on following trends Neurological exam GCS Transition 1:1 nursing to a nurse ratio of 1:4 Patient and Family Expectations Agitation & Patient Frustration with Recovery Changes in Medication Regimen Narcotic Wean Often rapid wean when transferring from ICU to floor Expected Wean 10% per Day Enhanced Communication Stimulation Control Balance between sensory overload and deprivation Environmental Modifications **Key Rancho Los Amigos Scale Awareness of current stage in the recovery process Turn to your COWS Pt is increasingly agitated Sweating HR increased to 130 BP 160/90 Febrile 39.2 C M: Metabolic O: Oxygenation V: Vascular E: Endocrine/Electrolytes/Environment S: Seizures T: Trauma/Tumor/Temperature U: Uremia P: Psychiatric I: Infection D: Drugs Labs return with Sodium Level of 129Meq/L Normal Sodium: mEq/L Most likely to Occur in Patient s with Large Contusions Symptoms Confusion Agitation Seizures Coma Diagnosis Assess Volume Status Urine Output Labs Uosmo Sosmo Chem 7 Na + 9

10 Volume Depletion CSW (salt loss) Fluid Replacement + Salt Tabs SNa+ <135 Sosmo <280 Una+ >20mEq/L Volume Expanded SIADH (H 2 O retention) Fluid Restriction Failure to distinguish CSW from SIADH in a hyponatremic patient with a brain injury will lead to inappropriate therapy and potentially exacerbate morbidity and mortality Monitor Intake and Output Replacement of both fluids and sodium Hydration with Normal Saline Na+ replacement First line is cc/hr NaCl 3gms Q6-8 Florinef mg PO Daily Pt is obtunded GCS 12 now 8 What are your concerns and interventions? What are your Priorities? Follow serum sodiums closely Respiratory insult Infection, PE, Hypoventilation Infection Hypotension, Fever, Sepsis Toxic Metabolic Hyponatremia Seizures Hydrocephalus New Bleed Head CT Apply O 2 via Face Mask Position on side to prevent aspiration DO NOT try to insert and airway Establish an IV, Prepare to administer benzodiazepines and anti-epileptic medications Ensure patient safety Institute seizure precautions 10

11 Formal Presentation at Interdisciplinary Team Rounds (IDT) Neurosurgery Social Work Rehab Services (PT,OT, ST, PM&R) Nutrition Eligibility Utilization Review Neurotrauma Outreach Neuropsychology Clinical Nurse Specialist Nursing The patient was considered to be medically stable and ready for Discharge Acute Rehabilitation Follows 90% of Commands Consistently Tolerate 2-3 hours of combined rehabilitation a day Must require Physical therapy and one other rehab discipline Average Stay 2-3 weeks Skilled Nursing Facility Rehabilitation Follows 75% of commands Tolerate 1-2hours of combined rehab in one day Average Stay <2 months Long-Term Skilled Nursing Facility Require Care >2 months Skilled needs for this level of care include Feeding Tube Rehabilitation Services Patients can receive rehabilitation services at this level if they are actively participating and making gains A patient becomes "custodial" when they don't have any skilled needs but require twenty-four hour care and can't go back to the community Patients can stay in this level of care for their lifetimes Subacute Care This level of care is for patients who are on a ventilator or have a tracheostomy tube and a feeding tube The purpose of these facilities is to wean patients off of their tracheostomies, if possible, and to transition them on to either rehabilitation or to a long term care facility There is a shortage of this level of care in Northern California Neurosurgery Clinic Traumatic Brain Injury Clinic Concussion Clinic Neurotrauma Outreach Program (NTOP) Immediate Hospital DC Follow-up Every Tuesday Morning Appointment Scheduling ereferral Direct Phone Line (415) TBI Support Group 11

12 Mission To provide transdisciplinary care for the patient with traumatic brain injury enhancing overall recovery, facilitating reintegration into the community, promoting emotional wellbeing, and providing supportive educational information. Trans-Disciplinary Team First Thursday of Every Month Appointment Scheduling ereferral Mission To provide multidisciplinary and supportive care for the patient with mild traumatic brain injury thru post-concussive assessment and symptom targeted patient education Multi-disciplinary Third Thursday of Every Month Appointment Scheduling ereferral Emphasis upon assertive tracking, outreach, and engagement into services Clinical case management to address all basic needs (medical, legal, financial, housing, services etc.) Coordination of care across medical, psychiatric, psychosocial, rehabilitation and social services Evidence-based psychotherapy to target psychiatric distress, increase interpersonal safety and help clients cope with the cognitive and behavioral changes associated with TBI. Currently employees Neuropsychologist Two full time licensed Social Workers Statistics NTOP provides services to 200 TBI patients annually with approximately 100 of those patients receiving more in-depth outreach services Mission: To provide emotional support and education to TBI patients and their families who are living with a traumatic brain injury. What does the TBI Support Group Provide Traumatic Brain Injury Education Peer Support and Mentoring Community resource referrals Invited speakers from numerous specialties (Neurology, Nutrition, Sleep, Rehabilitation, ect). Post-concussive Symptoms Need for Neuropsychology Testing Psychosocial Issues Reintegration in the Community 12

13 More than 75% of all Mild TBI patients report 1or more Symptoms Signs and Symptoms Physical Cognitive Emotional Sleep Patient Education Pt s who receive education around the s/s of concussion and the trajectory of recovery experience fewer symptoms overall Folders Leaders in Traumatic Brain Injury care ICP Monitoring in patients with GCS <8 Seizure Prophylaxis VTE Prophylaxis IDT Review 13

14 4/5/11 Random Sample of TBI Chart Audits TBI Program - NSU Stats May December 2010 (509 Total Patient Encounters) TBI Program TBI Program 2010 Performance Improvement Intracranial Pressure (ICP) Monitoring 2010 Performance Improvement Seizure Prophylaxis Quality Indicator: Intracranial Pressure (ICP) Monitoring Random sample of patients who have sustained a moderate to severe head injury and have a Quality Indicator: Seizure Prophylaxis (7 days of anti-seizure medication) GCS < 8 The following patients are excluded: death/comfort care, improving GCS / exam, coagulopathy, other clinical indications TBI Program 2010 Performance Improvement DVT Prophylaxis Quality Indicator: DVT Prophylaxis The following patients are excluded: isolated subarachnoid hemorrhage, clinical contraindication TBI Program 2010 Performance Improvement Interdisciplinary Team ( IDT) Rounds Quality Indicator: Interdisciplinary Team (IDT) Rounds Random sample of admitted TBI patients who have sustained a mild, moderate, or severe head injury Random sample of patients with TBI The following patients were excluded: Random sample of patients with TBI and abnormal CT scan ambulatory, coagulopathic, other clinical contraindications The following patients are excluded: hospital length of stay (LOS) < 7 days 14

15 Questions? 15