Measuring severity of TBI. Traumatic Brain injury: TBI. Glasgow Coma Scale & score. Glasgow coma scale/score. Glasgow coma scale with score (GCS)

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1 Measuring severity of TBI Glasgow coma scale with score (GCS) ก กก functional outcome Post traumatic Amnesia (PTA) cognitive & functional deficit Assist. Prof.Savai Norasan First National Neuroscience Conference Biotec, March25, pm Traumatic Brain injury: TBI Affected younger people (15-35 yrs) Male: female = 3-5: 1 (risk-taking behavior) Causes life long impairment in Physical Cognitive Behavioral & social function Social burden: family education & counseling Glasgow Coma Scale & score Glasgow Coma Scale Eye opening Verbal response Motor response Glasgow Coma Score Eye opening (scores 1-4) Verbal response (scores 1-5) Motor response (scores 1-6) ก Glasgow coma scale/score Primary brain damage - Cerebral concussion, Cerebral contusion, Cerebral laceration, Intracranial hemorrhage. Secondary brain damage- ก IICP, hypoxia, cerebral edema, hypotension 1

2 ก ก 1 Glasgow coma scale & neurological sheet CT brain Bilateral subdural hematoma (SDH) with cerebral edema with small Intraventricular hemorrhage (IVH) at occipital horn, Left lateral ventricle mild hydrocephalus with epidural hematoma (EDH) at left parieto-occipital lobe Diffuse brain swelling, 1.4 cm. midline shift to left, transtentorial & tonsilar herniation Multiple skull and base of skull fracture and pneumocephalus with cerebral contusion at right temporal lobe Day1-17/12/49 Eye opening (scores 1-4) Verbal response (scores 1-5) Motor response (scores 1-6) mild injury GCS (80 %) GCS moderate injury GCS 12-9 (10 %) severe injury GCS 8-3 (10 %) Operation 1 Craniectomy Intraoperation Hct 22 %-% PRC 6 units, FFP 2 units BP drop drip Dopamin (1:1) rate cc/hrs Fluid replacement D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days ก ก PTA ก ก ก ก 2 ก PE: GCS: E 1 V 2 M 1, pupils slightly react to light, RE 3 mm, LE 5 mm. Temp 37.2 C, Pulse 102/min, RR 36 /min, BP 140/80 mmhg, star shape Laceration wound at Left parietal area ~ 2.5 Cm, active bleeding Deformity left forearm Intubate ET tube Day Tracheostomy Day11, 28/12/49 Percutaneous Endoscopic gastrostomy (PEG) Day 29, 15/1/50 CT brain: Day32, 18/1/50 Blood clot at bilateral, 3 rd, 4 th ventricle, foramen of Magendie, & foramen of Lushka, increase hydrocephalus Increase external brain herniation 4. External Ventricular Drainage (EVD) Day33,, 19/1/50 2

3 Day45, 31/1/50-6/2/50 External Ventricular Drainage (EVD) Temp o C Over drainage content (CSF content ~250-1,000 CC/day) Flap Lumbar puncture UA-13/2/50- WBC TNTC, Urine culture-13/2/50- gram negative bacilli Day External Ventricular Drainage (EVD) - Day120, 18/4/50 CT brain- Day150, 18/5/50 Brain abscess with ventriculitis, meningitis, Increased brain swelling Obstructive hydrocephalus, right basal ganglia herniation CT brain- Day165, 2/6/50 Slightly decreased size of bilateral ventricle Severe degree of obstructive hydrocephalus Day /2/50 Ventriculo-peritoneal (VP) shunt- Day 70 (shunt reservoir obstruction) Ventriculo-peritoneal (VP) shunt- Day71, 28/2/50 Remove VP shunt (cloudy yellow CSF, flap ) Day80, 9/3/50 External Ventricular Drainage (EVD) (communicating hydrocephalus, yellowish CSF, slightly turbid)- Day87, 16/3/50 External Ventricular Drainage (EVD) - (Yellowish CSF, slightly turbid)- Day91, 20/3/50 Day Ventriculo-peritoneal (VP) shunt- Day194, 1/7/50 Ventriculo-peritoneal (VP) shunt- Day204, 1/8/50 CT brain- Day377, 29/12/50 Improve degree of obstructive hydrocephalus Day External Ventricular Drainage (EVD) - (Yellowish CSF, slightly turbid)- Day96, 25/3/50 External Ventricular Drainage (EVD) - (Yellowish CSF, slightly turbid)- Day106, 4/4/50 CT brain: Day115, 13/4/50 Multiple abscess at temporal lobe with meningitis, ventriculitis, obstructive hydrocephalus CSF culture MRSA Px. Vancomycin drip Vancomycin level peak 39.72, through 19.7 dose Vanco 500 mg IV q 8 hrs. 28/1/51 (Day 408) ~21.50 Temp o C ก ~3 Intubate ET tube with ventilator Dilantin IV drip Blood culture-staph Lumbar puncture WBC 24, PMN 52, Mono 40, RBC 50,000 Prot 1200, sugar 79 ATB- vancomycin 3

4 Problem lists IICP- Craniectomy,, CSF drainage Ventriculitis Prolong ventilator Post traumatic seizure Persistent vegetative State (PVS) Family support/spouse coping & skills Hemodynamic support SBP > 90 mmhg Mean arterial Pressure (MAP) ~ mmhg ICP< 15 mmhg. CPP > mmhg. Hematocrit ~ % If BP drop: Dopamine, dobutamine Maintain normovolemia- Avoid dehydration 0.9 % NSS, 3% 3 NSS Do NOT use D 5 W (increase( brain edema Elevated blood sugar; increase global cerebral ischemia lactic acid, lowering tissue ph Cycle of progressive brain swelling Arterial blood Pressure -spontaneous hypotension -Hypovolemia -Cardiogenic shock -Pharmacological Edema CSF CPP IICP Vasodilation Cerebral blood volume -Metabolic rate -Viscosity of blood -Hypoxia -Hypercarbia Positioning in IICP ก ก ก ก venous return flat head if hypotension ก ก ก BP drop.. (.. Hypovolemic... CPP ก ก ก Cerebral Vasodilate IICP) (Klein, 1999: 217) Management of IICP Hemodynamic support Respiratory management Positioning Osmotherapy: Osmotic agent, hypertonic saline Maintainance of normothermia Surgery: CSF drainage, craniectomy Respiratory management Normocapnia adequate oxygen, patent airway, and mechanical ventilation Hyperventilation: benefit after 24 hours?? (Use for road trips ) keep PaO 2 >70 mmhg keep PaCO mmhg (normal mmhg) Increase CO 2...Cerebral Vasodilation Decrease CO 2...Cerebral Vasoconstriction PaO 2 < = 40 mmhg cerebral vasodilation 4

5 Suctioning vs. IICP ก ก suction ICP> 20 mmhg, CPP< 70 mmhg. Aseptic tecnique, ก 2 ก 10 ก ~ 15 cm. 1/3 pressure mmhg. ก suction 1/2 ET tube/ Tracheostomy ก tracheal mucosal trauma. ก suction O % 1 Osmotic agent Mannitol 20% ( g/kg) 300 cc IV in 30 minutes, (prevent rebound effect) Reduce Hct. & blood viscosity. Increased CBF & cerebral O 2 delivery. Enhance fluid loss & hypovolemia Follow lab, serum osmolarity, serum Na/K Monitor dehydration signs: orthostatic hypotension, increase HR, CVP < 4, dry skin (Cook, Int. Crit. Care. Nurs., (2003) 19, ) Respiratory problems (Day1-227) (Day228) T-piece 5 ก 50 (Day 262) tracheos silver tube 25 ก 50 (Day 280) tracheostomy (Day 409) 6 ก 51- (Day 417) Tracheostomy Wean Oxygen T-piece15 L/min 18 ก 51- room air, monitor O 2 saturation Management of IICP Non osmotic agent Furosemide (Lasix) mg IV ก ICP PEEP> 5-10mmHg, ก ก ก Tracheostomy tube ก Excessive noise Painful procedure Unnecessary light Unfamiliar environment Pneumonia Postural drainage 2 Left lower Lung ก feed ก ก Nursing intervention VS IICP ก ก ก ICP ก ก ก ก ก Senses of comfort & reassurance ก ก pt coma IICP IICP (N =30, response 25) 5

6 Infection Meningitis Brain abscess Ventriculitis Treatment Sulperasone 3 gm IV q 12 hr Vancomycin 1 gm IV q 6 hr Tienam 500 mg IV q 8 hr Meronam 2 gm IV q 8 hr Augmentin 1.2 gm IV q 8 hr Nursing care for EVD ก ก ก กก ก /ก ก ก CSF ก ก ก CSF ก ก ก ก / ก ก ก Ventricle ก ก - ก ก Ventriculitis External ventricular drainage Incidence 40 % of EVD Main source of infection Skin exit site Connection between: Drain tube & ventricular catheter Bag & drain Risk factors Drain management > 4 External Ventricular drainage Ventriculostomy 6

7 Ventricular peritoneal shunt Post traumatic Seizure Classification Impact seizure (< 24 hrs after injury) Early seizure (<1 week after injury) Late seizure (> 8 days after injury) (Olson, S. (2004). Review of the role of anticonvulsant prophylaxis Following brain injury. J of Clinical Neuroscience, 11(1): 1-3) Post traumatic Seizure 18/12/49-28/1/50 Dilantin 250 mg % NSS 100 CC IV drip OD Elevate LFT Dilantin 50 mg/tablet x 2 Tube feed Dilantin- Off 2/2/50 28/1/51 focal & general tonic seizure Dilantin 1,000 mg % NSS 100 cc IV drip in 1 hr Then drip 100 mg IV q 8 hr.-off 4/2/51 Dilantin (50 mg/tablet) 2 tablets oral q 8 hr Lioresal ½ tablet x 3 pc. Antiepileptic drug Phenytoin (Dilantin) IV 0.9%NSS IV drip ก 50 mg/minute Monitor Blood pressure, EKG Side effect: skin rash, leukopenia, Steven Johnson syndrome, LFT, ataxia, vomiting, nystagmus, diplopia, drowsiness, gum hyperplasia Negative effects on cognition (Olson, S. (2004). Review of the role of anticonvulsant prophylaxis Following brain injury. J of Clinical Neuroscience, 11(1): 1-3) Post traumatic Seizure Phenytoin Risk factors GCS < 10 Cortical contusion Depress skull fracture EDH, SDH, ICH Penetrating head wound Seizure within 24 hrs of injury (Olson,S. (2004), Review of the role of anticonvulsant prophylaxis Following brain injury. J of Clinical Neuroscience, 11(1): 1-3) 7

8 ก AMBU passive exercise ก ก ก ก Blenderized diet (1:1) 400 cc X 4 fds ก Basic predictors outcome after TBI Age GCS Pupil reactivity Presence of major extracranial injury Consequence of TBI Physical disability Complication Pneumonia, DVT, pressure sore Complex neurological (Cognitive & behavioral) change Disrupt quality of life Research issues related to biotechnology Monitoring: IICP Partial pressure of brain tissue oxygenation (PbtO 2 ) Behavioral & personal issue Antiepileptic drug & cognition Mechanism to enhance cognitive function Neuroprotective strategies (IICP management) Neuroplasticity: Axon sprout Outcome indicators in severe TBI Length of stay in ICU Length of stay in hospital Post injury day fed (target day 3) Post injury day tracheostomy performed (target day 4) Number of ventilator days Incidence of pneumonia Research issues in TBI Medical complication Social reintegration/return to work Caregiver coping skills Psychosocial issues for spouse of TBI survivors Increase responsibilities Economic changes Dealing with unpredictable behavior New role as care giver 8