TBI Management Update: The 4th Edition of Guidelines for Management of Severe Traumatic Brain Injury

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2 TBI Management Update: The 4th Edition of Guidelines for Management of Severe Traumatic Brain Injury Mary Kay Bader RN, MSN, CCNS, FNCS, FAHA Neuro Critical Care CNS Mission Hospital Mission Viejo CA

3 Learning Objectives Relate the pathophysiology of Traumatic Brain Injury to the specific interventions needed to optimize brain physiology after severe TBI Describe the level I, II and III recommendations from the 2016 BTF guidelines Prioritize treatment options in managing severe TBI

4 Disclosure Statement Board of Directors: Secretary Neurocritical Care Society Honorarium Bard Integra Medical Advisory Board Brain Trauma Foundation Neuroptics Scientific Advisory Board Cerebrotech Stock options Neuroptics Cerebrotech

5 Successful Completion To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

6 Case DF: Pre Hospital 75 year old male riding bike with helmet on down hill went over the handlebars VS: BP 166/62 HR 44 R 18 O2 sat 82% on O2 Awake at seen: GCS deteriorating Laceration over left eye / blood coming from ears

7 Trauma Room 1143 Tier 1 Red BP 80/40 HR 50s RR 18 Intubated emergently in trauma room Neuro GCS Right eye 3 mm Left eye 4 mm Crepitus over left chest with suspicion of tension pneumothorax right Needle thorocostomies Bilateral chest tubes O2 saturation improves to 100% BP 120/60 Heart rate drops to 30s Patient arrests (Vfib) 10 minutes after arrival CPR x 6 minutes Defibrillation Epinephrine Thoracotomy performed Opened chest Blood products given To OR

8 IntraOp Left sided Thoracotomy cross clamped aorta Obvious cardiac contusion Multiple lung contusions Abdomen opened Grade 1 splenic injury Mesenteric hematoma Flail chest noted with bilateral hemothoraces Massive Transfusion 6 Packed RBCs, 4 FFP, and Super pack Platelets Abdomen left open with wound vac placed To CT

9 CT Non Contrast 224pm A David, A MI CT Head B BRAIN W 5/4/ LO CT HeH BRA 5/4/ f 36 1 C BRAIN W 5/4/ LO : 3 17 of 36 P C o cm 5/4/ , CT Head Brain wo BRAIN WO C 5/4/2016 2:27: SM THK H of 36 P Comp I of 70 Z C: W: 1 Compressed 111

10 Admit SICU 300pm Decision to induce hypothermia at 36 degrees C x 24 hours due to V Fib arrest Concerns about bleeding Neurosurgeon decides to hold ICP placement this evening Pads placed strategically with open belly Pacing wires present Bilateral chest tubes to suction VS stable MAP HR 56 Ventilated at 10 breaths/minute Neuro GCS Pupillometer Right pupil: NPI 1 CV 0.52 mm/sec Left pupil: NPI 0.5 CV 0.09 mm/sec

11 Repeat CT 827pm d, A A MIssion CT Head Brain w BRAIN WO ST 5/4/2016 8:27: LOC : -1 T A A MIssion A CT Head Brain w BRAIN WO ST H 5/4/2016 8:27: LOC : -9 TH C W Compressed A A MIssion A CT Head Brain w BRAIN WO ST H 5/4/2016 8:27: S 7 W Compressed A MIssion CT Head Brain BRAIN WO ST 5/4/2016 8:27: BRAIN WO 5/4/2016 8: LOC LOC : -8 TH LOC : - T P C W Compressed IM: 20 S P Compressed IM: 23 C

12 SICU 5/4 Night Shift Pupillometer 1800 R Eye NPI 0.8 CV 0.60 mm/sec L Eye NPI 0.6 CV 0.14 mm/sec VS BP decreases to 92/53 at 1830 HR 56 SVV 12% What is the right BP post arrest post TBI? What is the end point of resuscitation? Given Fluids to decrease SVV and improve MAP Improvement in BP after Fluid Bolus SVV 8% BP decreases again between Conversation occurs between Neurosurgeon and Neuro CNS

13 SICU Day 1 Temperature maintained at 36 degrees x 24 hours then rewarmed to 37 degrees Patient taken to OR for closure of abdomen and ICP/PbtO2 placement a 0800

14 CDC Definition of TBI

15 TBI Classification by Age Group Mechanism

16 Classification of Head Injury: Presentation

17 Mechanism of Injury Biomechanical contact acceleration deceleration rotational acceleration deceleration blast Mechanism Falls MVAs Sports Blast Induced neurotrauma PREVENTION IS PARAMOUNT!

18 Severe TBI Sum score 3 to 8 &/or motor score <5 Brain injury association Prolonged unconscious state or coma lasting days, weeks or months Primary Injury Occurs at the time of the event Includes EDH, SDH, SAH, Contusions, DAI etc

19 Secondary Brain Injury Secondary Head Injury Extracranial causes Hypotension Hypocapnia and Hypercapnia Hypoxia Anemia Hyperglycemia & Hypoglycemia Hyperthermia

20 Cerebral Blood Flow Autoregulation Vasomotor control Intact: Increase in CPP causes vasoconstriction and decrease in ICP Vasomotor reactivity failure: Increase in CPP causes vasodilation and inc ICP Flow metabolism metabolism CBF Metabolic substances PaO2 PaCO2 ph i.e., acidosis = vasodilatation

21 Cerebral Blood Flow CBF = CPP CVR CPP = MAP ICP Optimal CPP mm Hg and sometimes higher in TBI Normal CPP does not ensure CBF is adequate to meet the needs of the injured brain CBF Autoregulation CBF MAP

22 Cerebral Blood Flow CBF = CPP CVR CPP = MAP ICP Optimal CPP >60 mm Hg and sometimes higher in TBI Normal CPP does not ensure CBF is adequate to meet the needs of the injured brain CBF Autoregulation Mean Arterial Pressure MAP CBF

23 Cerebral Autoregulation The state of autoregulation should likely have impact on management of cerebral perfusion targets. Critical autoregulatory thresholds vary with age, sex, and stage of ABI. PRx and other indices can assess CA real time and be used to calculate CPP Opt. Titrating therapy to CPP Opt requires verification of safety and validation in prospective clinical trials. Slide credit: NCS Multimodality Monitoring Marek Czosnyka & Chad Miller

24 Autoregulation Prx ICP and CPP Relationship Correlation ( 1 to 0) As CPP increases, ICP decreases Indicates intact cerebrovascular reactivity + Correlation (>0 to 1) As CPP increases, so does ICP Indicates the loss of cerebrovascular reactivity Pressure passive dilatation

25 Autoregulation Concept of Prx measurement as a dynamic assessment of cerebral autoregulation.5 PRx show the U shape relationship with mean CPP (200 patients!). This indicate that for low CPP and CPP above 90 mm Hg both autoregulation and pressure reactivity are defective. PRx Cerebral Perfusion Pressure (mm Hg) Slide credit: NCS Multimodality Monitoring Marek Czosnyka & Chad Miller Steiner LA at al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med Apr;30(4):733 8.

26 ICP: Why? ICP Dynamic relationship between intracranial contents and the pathophysiology of injury Increases in tissue volume Increase in blood volume Increase in CSF volume If ICP exceeds BP, no blood flow to the brain

27 Physiologic Changes: Intracranial Pressure Theories on Brain Compartment 80% brain 10% blood 10% CSF If one increases the other two decrease Compensatory mechanisms 80% Brain moves over 1 0 % SDH Venous blood to heart 1 0 % CSF shunts to spine SAS

28 Symptoms of Increased ICP: Adults Early Altered level of consciousness, restless, agitated, headache, nausea, and contralateral motor weakness cranial nerves III and VI Late Coma, vomiting, contralateral hemiplegia, and posturing Alteration in Vital Signs Impaired brainstem reflexes Pupils, dysconjugate gaze

29 ICP Monitors Location Intraventricular most efficient/drain CSF Anatomic landmarks anterior to the coronal sutures, 3 4 cm off the midline, are used to place the catheter in the anterior horn of the lateral ventricle (usually the non dominant hemisphere). Tip will be near the foramen of Monro. The catheter may be tunneled subcutaneously, or a bolted catheter may be inserted. If tunneled, the catheter exits from the scalp through a separate surgical stab wound. Catheters may be externally transduced via a strain gauge transducer; hybrid catheters also have an internal strain gauge microchip or fiberoptic transducer.

30 Intracranial Pressure Normal range 0 15 mm Hg Abnormal ranges > 20 mm Hg Cerebral Perfusion Pressure MAP ICP = CPP Optimal CPP in TBI 2016: mm Hg

31 Intracranial Pressure: It is more than a number it is all about compliance!

32 Systemic and Brain Oxygenation: Why? Maintenance of adequate oxygenation is 1 o objective of critical care Assessment of tissue oxygenation essential Hypoxia Reduction of tissue oxygenation to levels insufficient to maintain cellular function and metabolism May be a result of ischemia due to macro vascular/microvascular, anemia, & hypoxemia Cytopathic hypoxia: failure of cell to extract O2 Aggravates secondary brain damage Monitor and Treatment paramount

33 Oxygen Dynamics: Brain Tissue Oxygen Monitoring

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35 Study Group 56 patients Normal SjO2 (55% 75%) 30 patients (54%) 13 patients low ICP (23%) 17 patients high ICP (31%) Low SjO2 & high ICP (> 20 mm Hg) 7 patients (13%) Low SjO2 & low ICP (< 20 mm Hg) 19 patients (34%)

36 Oxygen flux from air to neuron O2 mmhg Alveolus Artery Capillarie s PO2 Tissue Cytosol Mitochondri a End Capillary PO 2

37 Brain Tissue Oxygen (Pbt02) Normal: mm Hg Risk of death increases < 15 mm Hg for 30 minutes < 10 mm Hg for 10 minutes PbtO2 < 5 mm Hg high mortality PbtO2 <2mm Hg neuronal death

38 Placement of LICOX Regional Detection Penumbra Area Global Measurement Contralateral to Injury

39 CPP & PbtO2

40 Interventions and PbtO2 Decreasing PbtO2 Hypoxia Low Hemoglobin Decreasing PaCO2 Increased ICP Decreased MAP/CPP Increasing temperature Vasospasm Systemic Causes Pulmonary Cardiac/Hemodynamic Increasing PbtO2 Increasing FIO2 Increasing Hemoglobin Increasing PaCO2 Draining CSF ICP < 15 mm Hg Increasing CPP/MAP Decreasing temperature Barbiturates

41 Influence of Airway/Ventilation Issues Day 8: Lungs Worsening ICP is no longer an issue CO2 42 FIO2 % 80 MAP 71 ICP 14 CPP 56 PbtO Interventions Increase Dopamine Chest x-ray reviewed; Order to prone patient Hours go by sudden change in PbtO Lung sounds ; Supine; chest xray- Pneumo 100 Chest tube placed FIO2 weaned

42 Coming to a hospital close to you. BOOST 3

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44 Managing Severe TBI 2015 ACS TQIP Guidelines

45 TBI Guidelines Joint Projects of The Brain Trauma Foundation American Association of Neurological Surgeons (AANS) Congress of Neurological Surgeons (CNS) AANS/CNS Joint Section on Neurotrauma & Critical Care

46 Patients are 2x as likely to survive if TBI guidelines are followed Proportion of patients with good outcomes rose from 35% to 66% Proportion of patients with poor outcomes fell from 34% to 19% Potential savings of $3.8 Billion Faul M, et al. J Trauma 2007;63:1271-8

47 4 th Edition TBI Guidelines Living Guidelines 4th Edition is transitional, there will not be a 5 th produced Moving to a model of continuous monitoring of literature, rapid updates to evidence review, and revisions to recommendations as evidence warrants Why? Advances in technology, increasing volume of available information, and the change in expectations among clinicians and other stakeholders A static document updated every few years no longer serves the demands of the community

48 4th Edition: Assessing Evidence Assessing the quality of evidence 4 domains Aggregate quality of the studies Consistency of the results Whether the evidence provided is direct or indirect Precision of the evidence Also considered the number of studies and subjects Based on these, an overall assessment is made regarding the quality of the body of evidence: high, moderate, low, or insufficient Recommendations changed! If insufficient evidence, asked to state prior ones Does NOT address routine general ICU care

49 4 th Edition Topics Treatments Decompressive Craniectomy* Prophylactic Hypothermia* Hyperosmolar Therapy Cerebrospinal Fluid Drainage* Ventilation Therapies Anesthetics, Analgesics, and Sedatives Steroids Nutrition* Infection Prophylaxis* DVT Prophylaxis Seizure Prophylaxis* * New or revised in 2016 Monitoring Intracranial Pressure Cerebral Perfusion Pressure Advanced Cerebral Monitoring Thresholds Blood Pressure Intracranial Pressure Cerebral Perfusion Pressure Advanced Cerebral Monitoring Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

50 Decompressive Craniectomy* Level II A Bifrontal DC is not recommended to improve outcomes as measured by the GOS E score at 6 months post injury in severe TBI patients with diffuse injury (without mass lesions), and with ICP elevation to values >20 mm Hg for more than 15 minutes within a 1 hour period that are refractory to firsttier therapies. However, this procedure has been demonstrated to reduce ICP and to minimize days in the intensive care unit (ICU). A large frontotemporoparietal DC (not less than 12 x 15 cm or 15 cm diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurologic outcomes. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

51 Rescue ICP Trial NEJM 2016: 375(12)

52 RESCUEicp NEW DATA Definition of refractory ICP: >25 mm Hg for 1 12 hrs Decompression technique left up to surgeon Results Surgical arm: better ICP control, lower mortality, higher rates of vegetative state, lower & upper severe disability Rates of moderate & good recovery categories similar between groups Prespecified analysis looked at favorable (GOS E 4 8) vs unfavorable outcomes was similar at 6 months (surgery 42.8%; medical 34.6%), but significant difference seen at 12 months (surgery 45.4%; medical 32.4%). Hutchinson PJ, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med Published online

53 Rescue ICP

54 Prophylactic Hypothermia* Level II B (change from level III) Early (within 2.5 hours), short term (48 hours postinjury) prophylactic hypothermia is not recommended to improve outcomes in patients with diffuse injury. Caveats: Targeted Temperature Management? Refractory ICP control? for experts only Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

55 Hyperosmotic Therapy Mannitol Osmotic effect delayed for 15 to 30 minutes while gradients established opening of BBB mannitol accumulation reversed osmotic shift brain osmolality exacerbates ICP by brain edema = REBOUND ICP Never subjected to randomized, placebo controlled trial Hypertonic Saline Volume expander w/ minimal renal effects so maintains MAP with less tendency to cross BBB than mannitol Limited studies; resuscitation vs ICP control Variable concentrations (1.7% 29.2%) / administration Most report Na + levels of

56 Hyperosmolar Therapy Not Evidence Based: Recommendations from Prior Edition not supported by current evidence standards Mannitol is effective for control of raised intracranial pressure (ICP) at doses of 0.25 g/kg to 1 g/kg body weight. Arterial hypotension (systolic blood pressure <90 mm Hg) should be avoided. Restrict mannitol use prior to ICP monitoring to patients with signs of herniation or progressive neurological deterioration not attributable to extracranial causes. Note: Data on hypertonic saline still limited Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

57 CSF Drainage* Level III An EVD system zeroed at the midbrain with continuous drainage of CSF may be considered to lower ICP burden more effectively than intermittent use. Use of CSF drainage to lower ICP in patients with an initial Glasgow Coma Scale (GCS) <6 during the first 12 hours after injury may be considered. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

58 Ventilation Strategies Level II B Prolonged prophylactic hyperventilation with PaCO2 of 25 mm Hg or less is not recommended Not Evidence Based: Recommendations from Prior Edition not supported by current evidence standards Hyperventilation is recommended as a temporizing measure for the reduction of elevated ICP. Hyperventilation should be avoided during the first 24 hours after injury when CBF is often critically reduced. If hyperventilation is used, SjO2 or PbtO2 measurements are recommended to monitor oxygen delivery. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

59 Anesthetics, Analgesics, & Sedatives Level II B Administration of barbiturates to induce burst suppression on EEG as prophylaxis against development of intracranial hypertension is not recommended. 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. Although propofol is recommended for control of ICP, it is not recommended for improvement in mortality or 6 month outcomes. Caution is required as high dose propofol can produce significant morbidity Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

60 Steroids Level I The use of steroids is not recommended for improving outcome or reducing ICP. In patients with severe TBI, high dose methylprednisolone was associated with increased mortality and is contraindicated. Notes: 1. CRASH trial (10k pts) showed increased mortality. (Lancet 2004; 364: ) 2. Detrimental systemic effects: shown to cause hyperglycemia, infections, other complications Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

61 Nutrition* Level II A Feeding patients to attain basal caloric replacement at least by the 5th day and at most by the 7th day post injury is recommended to decrease mortality. Level II B Transgastric jejunal feeding is recommended to reduce the incidence of ventilator associated pneumonia. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

62 Infection Prophylaxis* Level II A Early tracheostomy is recommended to reduce mechanical ventilation days when the overall benefit is felt to outweigh the complications associated with such a procedure. However, there is no evidence that early tracheostomy reduces mortality or the rate of nosocomial pneumonia. The use of povidone iodine oral care is not recommended to reduce ventilator associated pneumonia and may cause an increased risk of ARDS. Level III Antimicrobial impregnated catheters may be considered to prevent EVD related infections. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

63 DVT Prophylaxis Level III LMWH or SQ heparin may be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial hemorrhage. In addition to compression stockings, pharmacologic prophylaxis may be considered if the brain injury is stable and the benefit is considered to outweigh the risk of increased intracranial hemorrhage. There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for DVT. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

64 Anti seizure Prophylaxis* Level II A Prophylactic use of PTN or VPA is not recommended for preventing late PTS. PTN is recommended to decrease the incidence of early PTS (within 7 days of injury), when the overall benefit is felt to outweigh the complications associated with such treatment. However, early PTS have not been associated with worse outcomes. At the present time there is insufficient evidence to recommend LEV over PTN regarding efficacy in preventing early PTS and toxicity. Note: Consider ceeg monitoring Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

65 ICP Monitoring* Level II B Management of severe TBI patients using information from ICP monitoring is recommended to reduce in hospital and 2 week postinjury mortality. Not Evidence Based: Recommendations from Prior Edition not supported by current evidence standards ICP should be monitored in all salvageable patients with a severe TBI & abnormal head CT 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: age over 40 years, unilateral or bilateral motor posturing, or SBP <90 mm Hg. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

66 CPP Monitoring* Level II B Management of severe TBI patients using guidelines based recommendations for CPP monitoring is recommended to decrease 2 week mortality Note: No discussion of CPP opt as data limited Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

67 Advanced Cerebral Monitoring Level III Jugular bulb monitoring of AVDO2, as a source of information for management decisions, may be considered to reduce mortality and improve outcomes at 3 and 6 months post injury. Note: Data on PbtO2 remains observational, unable to determine benefit of monitoring Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

68 Blood Pressure Thresholds* Level III Maintaining SBP at 100 mm Hg for patients 50 to 69 years old or at 110 mm Hg or above for patients 15 to 49 or over 70 years old may be considered to decrease mortality and improve outcomes. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

69 ICP Treatment Threshold* Level II B Treating ICP above 22 mm Hg is recommended because values above this level are associated with increased mortality. Level III A combination of ICP values and clinical and brain CT findings may be used to make management decisions. Real life note: accept an ICP range of mm Hg if other parameters (CPP, PbtO2, SjvO2) are acceptable Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

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71 CPP Thresholds* Level II B The recommended target CPP value for survival and favorable outcomes is between 60 and 70 mm Hg. Whether 60 or 70 mm Hg is the minimum optimal CPP threshold is unclear and may depend upon the patient s autoregulatory status. Level III Avoiding aggressive attempts to maintain CPP above 70 mm Hg with fluids and pressors may be considered because of the risk of adult respiratory failure. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

72 Advanced Cerebral Monitoring Thresholds Level III Jugular venous saturation of <50% may be a threshold to avoid in order to reduce mortality and improve outcomes. Notes: 1. Evidence suggests that episodes of desaturation (SjO2 < 50 55%) are associated with worse outcomes and high extraction (AJVO2) are associated with good outcome. 2. Low values of PbtO2 (< mm Hg) & their duration (> 30 minutes) are associated with higher mortality. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition: Executive Summary. Journal of Neurosurgery published online

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74 Purpose of MMM Provide evidence based recommendations about monitoring in neurocritical care patients Identify expert authors in NCC, neurosurgery, neurology, critical care, neuroanaesthesia, nursing, pharmacy and informatics. Perform a system literature review to develop recommendations about specific processes inherent to NCC and present recommendations based on evidence using GRADE criteria

75 Topics Covered

76 Systemic Hemodynamics

77 Intracranial Pressure and Cerebral Perfusion Pressure

78 Cerebral Autoregulation

79 Systemic and Brain Oxygenation

80 Cerebral Microdialysis

81 Glucose and Nutrition

82 Critical Care Management of Severe TBI Pathological Changes Secondary Injury Dynamics of Injury & Monitoring Technologies Evidence Based Practice Coordinated ICU Multidisciplinary Care

83 Admission to the ED Trauma Room Standardize Team interventions to assure the brain is prioritized!

84 Severe TBI Patient: GCS 3 8 CT+ Injury Arrival: Emergency Department Trauma Bay Assess A B C: Oxygenation and Ventilation Airway: Secured with RSI Breathing: Connect to Ventilator Avoid hyperventilation Use Capnography to monitor ET CO2 (35) RSI: Lidocaine 1mg/kg IVP Etomidate 0.3 mg/kg IVP Paralytic of Choice Follow-up: Versed/Fentanyl prn

85 Severe TBI Patient: GCS 3 8 CT+ Injury Arrival: Emergency Department Trauma Bay Assess A B C: Oxygenation and Ventilation Assess Circulation: Assess Pulse, ECG and BP IV fluids to maintain adequate MAP Place Foley & OG Maintain MAP > 80 mm Hg with IV NS: Assess need for Blood Products and/or Vasopressors Assess need for Central Line/Arterial Line

86 Severe TBI Patient: GCS 3 8 CT+ Injury Arrival: Emergency Department Trauma Bay Assess Neuro: GCS/Pupils If S/S Increased ICP Non-reactive single pupil(s) &/or Posturing Administer 3% Saline 200 ml (Preferred) or Mannitol 1gm/kg IV (if no signs hypotension or bleeding)

87 Severe Brain Injury Algorithm Secondary Survey Other Interventions as needed Is patient on any anti-coagulants or anti-platelet medications? Anticoagulation/Anti-platelet Reversal PCC agents Platelets/FFP DDAVP Radiology: CT Scan Non-Contrast/C-Spine Positive for Bleeding? PACU: Hold/Lines Placed if time Place Central Line/Art line with Flotrac OR: Monitors (ICP/PbtO2)/Craniotomy ED Trauma or SICU RN assist in OR

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89 Severe TBI Patient: GCS 3 8 CT+ Injury ICU Care: Primary Interventions Admit to ICU A & B: Oxygenation/Ventilation Optimization Circulation: Maintain CPP >60 mm Hg as initial target Autoregulation Testing: Intact may need CPP up to 80 mm Hg ICP Management: Draining CSF and Providing Sedation/Analgesia

90 Teamwork Primary Intervention: Intracranial Pressure CSF Drainage Normal range 0 15 mm Hg Abnormal ranges > 20 mm Hg Compliance waveform analysis

91 Teamwork Primary Intervention: Optimal Sedation /Analgesia Analgesia Fentanyl Sedation Propofol Benzodiazepines Precedex

92 Teamwork Secondary/Tertiary Interventions Secondary Interventions HTS Mannitol Tertiary Interventions Pentobarb coma Decompressive hemicraniectomy Mild Hypothermia

93 Back to DF

94 CT Post ICP Placement 5/5 1147pm avid, A 0 A MIssion CT Head Brain BRAIN WO ST 5/5/ :47: LOC : 16 T David, A A MIssi CT Head Bra BRAIN WO 5/5/ : LOC : 90 1 CT Head B BRAIN W 5/5/ LOC 0 0 f 210 P Compressed IM: of 210 Compress 2 of 210 Compr BRAIN W 5/5/ LO

95 SICU Day 2 Post OP Guiding MAP according to PbtO

96 ICP/PbtO2 monitor placed RT concerns about Brain Hemodynamics

97 Brain Perfusion ICP 3 15 mm Hg It is NOT a intracranial pressure problem! ECG rhythm changes brady tachypauses Pacer wire accessed

98 Brain Perfusion is Heavily Dependent on Blood Pressure

99 Brain Perfusion Dependent on Other PaCO2

100 Brain Perfusion is Heavily Dependent on Blood Pressure & ECG

101 Brain Perfusion is Heavily Dependent on Blood Pressure & ECG

102 Brain Perfusion What s the Target?

103 Sudden Event Electrical events continue

104 Days 5 10

105 Progress in ICU Day 6 Attempted to wean sedation/analgesia ICP increased to 30s Decision to keep sedated x 24 hours Day 7 10 ICP/PbtO2 removed on Day 7 Fluid overload issues Lasix daily Weaning sedation Precedex drip Follows commands Extubated on Day 9 Day 14 PE Started on Heparin Drip Day 15 Up in chair Back in bed patient has coffee ground emesis with aspiration Arrest 1 3 minutes PEA CPR with epinephrine and Reintubated

106 Progress in ICU Day 15 Stop Heparin Days Bronched daily x 3 Weaning sedation on Day 19 Day 23 Extubated again Failed swallow evaluation Day 28 PEG placed Day 30 Transferred to ARU Discharged home on Day 14 (Day 44)

107 Outcome Supervised level for bed mobility and min/contact guard assist for transfers. Ambulating 160 feet with only supervision. ADL skills have improved to supervised/contact guard assist. Cognitively, the patient has improved to moderate assist with memory and min assist for problem solving tasks. The patient's family has received training from the therapy team.

108 Conclusion Protocolize and Individualize