Traumatic Brain Injury Pathways for Adult ED Patients Being Admitted to Trauma Service
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1 tic Brain Injury Pathways for Adult ED Patients Being Admitted to Service Revision Team Tyler W. Barrett, MD, MSCI Elizabeth S. Compton, NP Bradley M. Dennis, MD Oscar D. Guillamondegui, MD, MPH Michael S. Norris, RN Mayur B. Patel, MD, MPH Rebecca A. Reynolds, MD Jacob P. Schwarz, MD Reid S. Thompson, MD Specialty Emergency Medicine Process Improvement Presented at MDTC/TPOPPs: 06/27/2018 Presented at Faculty Meeting: 09/05/2018 Last Discussed at MDTC/TPOPPS: 10/30/2018 Last Discussed at ED Executive Meeting: 11/07/2018 Last Updated: 11/09/2018 CBC Cl CPP CSF CT CVP d DVT ED EEG EDH EVD FFP GCS h HOB ICH ICP INR IPH MDTC ml Na NSU PaCO2 PaO2 PI PT PTT Q SAH SBP SDH TBI TICU TPOPPS ABBREVIATIONS Complete Blood Count Chloride Cerebral Perfusion Pressure Cerebrospinal Fluid Computed Tomography Central Venous Pressure Day Deep Venous Thrombosis Emergency Department Electroencephalography Epidural Hematoma External Ventricular Drain Fresh Frozen Plasma Glasgow Coma Scale Hour Head of Bed Intracerebral/Intraparenchymal Hematoma/Hemorrhage Intracranial Pressure International Normalized Ratio Intracerebral/Intraparenchymal Hematoma/Hemorrhage Multidisciplinary Conference Milliliter Sodium Partial pressure of Carbon dioxide Partial pressure of Oxygen Process Improvement prothrombin time partial thromboplastin time Every Subarachnoid hemorrhage Systolic Blood Pressure Subdural Hemorrhage tic Brain Injury Intensive Care Unit Program Operational Process Performance Committee
2 Minimal tic Brain Injury Pathway for Adult ED Patients Being Admitted to Service Positive Head CT Blunt GCS = 15 without seizures at Consultation for Admission Pre-injury Anticoagulants or Antiplatelet agents? NO YES Isolated pneumocephalus With/without Non-displaced Skull Fracture Q4h Neurological checks For 24h post-injury Surgery OK 12h post-injury Speech-Cognition Consult Post-TBI Seizure/DVT Protocols tic SAH present With/without Non-displaced Skull Fracture Q2h Neurological checks For 24h post-injury Surgery OK 12h post-injury Speech-Cognition Consult Post-TBI Seizure/DVT Protocols Concerns &/or Other Findings (e.g., IPH, EDH, SDH, Non-traumatic bleed, Displaced skull fracture, ED attending request) Consultation New/Progressive CT Findings Any Decline in Neurologic Exam Unexplained GCS decline New focal neurologic sign or Seizure Abnormal pupillary exam New Delirium New Agitation STAT Head CT
3 tic Brain Injury Pathway, GCS 9-15 Positive CT Head in Adult ED Patient Being Admitted to Service Failed Minimal TBI Pathway or GCS 9-15 (any mechanism) on initial evaluation TRAUMA SERVICEADMISSION Consult Consult Speech-Pathology 7d Seizure prophylaxis protocol CBC, PT/INR, PTT Consider Reversal of Anticoagulant/Antiplatelet Use Consider Repeat Imaging within 6-24h, if any of following: High Risk CT Features: 1. Subdural 2. Epidural 3. Intracerebral hemorrhage Clinical Deterioration Anticoagulant/Antiplatelet Use Consultant request
4 tic Brain Injury Pathway, GCS < 9 ADULT ED PATIENT ADMITTED TO TRAUMA WITH POSITIVE HEAD CT Consult ( Attending & Attending to have Direct Conversation for Major Diverging MultiTeam Plans) Consult Speech-Pathology 7d Seizure prophylaxis protocol; Arterial Blood Gas, CBC, PT/INR, PTT Intubation Keep PaCO , PaO 2 >60 HOB > 60 degrees (or reverse Trendelenberg until Spine cleared) SBP > 90 mm Hg Consider FFP (and/or K-Centra) and Platelet transfusion for target INR<2.0 / Platelet > 100K Establish central access, arterial line; Maintain Euvolemia Optimize Sedation and Analgesia, Consider Paralysis Low threshold for Hyperosmolar Therapy If ICP Monitor Placed CPP<60 1 st line: Phenylephrine 2 nd line: Norepinephrine CPP<60 If EVD, then drain CSF Contact TICU attending and/or fellow Contact (decompressive craniectomy vs. pentobarbital coma) Monitor Intra-abdominal pressures Consider pentobarbital coma with Neurology consult (Continuous EEG) Consider Palliative care consult Hyperosmolar Therapy 3% ml/hr CVP High: Mannitol bolus q6h CVP low: 3% NaCl bolus q6h Q6h BMP, Osm Max: Na 160, Osm 320 Persistent and/or CPP < 60
5 REFERENCES Mild-Moderate TBI Haydel. Clinical decision instruments for CT scanning in minor head injury. JAMA (2005) vol. 294 (12) pp Haydel. The Canadian CT Head Rule. Lancet (2001) vol. 358 (9286) pp Haydel et al. Indications for computed tomography in patients with minor head injury. N Engl J Med (2000) vol. 343 (2) pp Jagoda. Mild traumatic brain injury: key decisions in acute management. Psychiatr Clin North Am (2010) vol. 33 (4) pp Joseph B, Pandit V, Haider AA, et al. Improving Hospital Quality and Costs in Nonoperative tic Brain Injury: The Role of Acute Care Surgeons. JAMA Surg (2015) vol 150(9) pp Menon et al. Position Statement: Definition of tic Brain Injury. Arch Phys Med Rehabil (2010) vol. 91 (11) pp Thurman and Guerrero. Trends in hospitalization associated with traumatic brain injury. JAMA (1999) vol. 282 (10) pp Severe TBI Carney N, Totten AM, O Reilly C, et al. Guidelines for the Management of Severe tic Brain Injury, Fourth Edition. 2016;80(1):6 15. Feinstein et al. Resuscitation with pressors after traumatic brain injury. J Am Coll Surg (2005) vol. 201 (4) pp Marshall et al. Pentobarbital coma for refractory intra-cranial hypertension after severe traumatic brain injury: mortality predictions and one-year outcomes in 55 patients. J (2010) vol. 69 (2) pp Patel MB, Guillamondegui OD. Severe tic Brain Injury: Medical and Surgical Management. Section: Head Injury. In: Papadakos P, Gestring M, editors. Encyclopedia of Care. Heidelberg, Berlin: Springer-Verlag; p Vella M, Crandall MA, Patel MB. Acute Management of tic Brain Injury. Surgical Clinics of North America. 2017; 97(5): PMCID: PMC Wakai et al. Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev (2007) (1) pp. CD001049
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