PROTECT - ION 11/26/2014. Traumatic Brain Injury. Pathophysiology and Management. Disclosures. Neuro PROTECTion in Severe Traumatic Brain Injury

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1 Disclosures Neuro PROTECTion in Severe Traumatic Brain Injury Presented by: Mary Kay Bader RN, MSN CCNS, CNRN, CCRN, SCRN, FAHA, FNCS Neuro/Critical Care CNS Mission Hospital Bader Honorarium Bard, Neuroptics, & The Medicines Company AANN: Immediate Past President NCS Board of Directors Stock Options: Neuroptics Medical Advisory Board Brain Trauma Foundation Neuroptics PROTECT - ION P = Physiologic Changes from TBI R = Resuscitation O = Operative Intervention T = Technology E = Entry to ICU C = Coordinated Care/Clinical Guidelines T = Teamwork & Family Centered Care Traumatic Brain Injury Pathophysiology and Management Pathological Mechanisms Direct Indirect Mechanism of Injury Blunt Falls MVAs Struck by object Penetrating -90% die Compression Blast Classification Classification by Age Group - Mechanism 1

2 Classification of Head Injury: Presentation Primary Head Injury Occurs at the time of injury Compromised skull integrity tearing of vessels/sinuses dural tears brain contusions cranial nerve injuries Compromised brain integrity linear and rotational forces Prevention is paramount to alter primary injury Physiology Changes in Brain Injury Primary Injury: Epidural Hematoma Primary Injury Skull integrity Fractures Basilar Depressed Linear Physiology Changes in Brain Injury Cerebral Contusions Primary Injury Subdural hematoma Focal injuries Diffuse injuries Types: Fracture Coup Countercoup Herniation Surface Gliding (focal hemorrhage in cortex/subjacent white matter found in DIA Frequently frontal or temporal regions Vasogenic edema and central necrosis Diagnosis: CT and Exam 2

3 Diffuse Axonal Injury Primary Head Injury Extensive disruption of axons/white matter in both hemispheres Stress of gray-white interface Petechial hemorrhages Axonal shearing/swelling Diagnosis: CT and exam Results of compromised brain integrity and cellular changes cerebral edema hemorrhage/hematomas herniation brain death Secondary Injury: Alteration in CBF Numerous studies have found low CBF in early hours after TBI Martin et al study on CBF in TBI 1 st 12 to 24 hours: Hypoperfusion/decrease in CBF 24 hours to Day 5: CBF exceeding CMRO2 Days 5/6 to 14: Slow flow due to vasospasm CBF altered but it must be balanced with metabolism and oxygenation Physiology Changes in Brain Injury Secondary Injury Extracranial causes Hypotension Hypocapnia and Hypercapnia Hypoxia Anemia Acidosis Hyperglycemia Hyperthermia 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 3

4 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 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 Resuscitation 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 Assess Circulation: Pulse, ECG and BP Resuscitation Severe TBI Patient: GCS 3-8 CT+ Injury Arrival: Emergency Department Trauma Bay Hypertonic Saline Posturing Fixed non-reactive pupil Fluid Resuscitation IV fluids to maintain adequate MAP 80 mm Hg Arterial line/foley/og Resuscitation Severe Brain Injury Algorithm Operative Intervention CT scan OR Priorities Vent:100% FIO2 and PaCO Place PA catheter; PbtO2; ICP Optimize MAP > 90 mm Hg Fluids Correct coagulopathies Propofol to reduce CMRO2/ICP Operative Intervention as indicated Removal of SDH/EDH Craniectomy Placement of monitors 4

5 Operative Intervention Severe TBI Patient: GCS 3-8 CT+ Injury Operative Intervention Severe TBI Patient: GCS 3-8 CT+ Injury Technology Technology Intracranial Pressure Technology Place ICP monitor Treat for ICP > 20 mm Hg Clinicians should use a combination of ICP, clinical and brain CT finding to guide treatment Consider placement of PbtO2 monitor and treat PbtO2 < 15 mm Hg Place Hemodynamic Monitors and Regulate CPP mm Hg Normal range 0-15 mm Hg Abnormal ranges moderate severe > 40 Technology Oxygenation Delivery of oxygen to the brain dependent on Lungs Hemoglobin and Plasma Preload (CVP) /Cardiac Output/ Afterload (SVR) CBF = CPP/CVR Autoregulation Chemical Vasomotor control PaCO2 / PaO2 / ph Technology Oxygen Dynamics: Brain Tissue Oxygen Monitoring Flow Metabolism metabolism/flow metabolism/flow 5

6 Technology 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 Technology Brain Tissue Oxygen(Pbt02) Decreasing PbtO2 Hypoxia Low Hemoglobin Decreasing PaCO2 Increased ICP Decreased MAP/CPP Shivering Vasospasm Systemic Causes Pulmonary Cardiac/Hemodynamic Increasing PbtO2 Increasing FIO2 when PaO2 < 80 mm Hg Increasing Hemoglobin Increasing PaCO2 Draining CSF Increasing CPP/MAP Control shivering Barbiturates Outcomes: TBI 41 pts ( ) vs 139 ( ) CPP & PbtO2 Entry into the ICU 6

7 Coordinated Care BTF: Core TBI Management BTF 2007 Severe TBI Guidelines Place ICP and cerebral ischemia monitor Core interventions Drain CSF CO mm Hg Sedation/Analgesia Normothermia T 37 CPP mm Hg BP & Oxygenation Hyperosmolar Tx Prophylactic Hypothermia DVT Prophylaxis Indications for ICP Monitoring ICP Monitoring Technology ICP Thresholds CPP Thresholds Brain Oxygen Monitoring &Thresholds Anesthetics, Analgesics, & Sedatives Nutrition Anti-Seizure Hyperventilation Steroids Coordinated Care/Clinical Guidelines Intensive Care Unit A & B: Oxygenation/Ventilation Optimization Target PaCO2: 35 mm Hg (Day 1) & (Days2-5) Circulation: Maintain CPP mm Hg as initial target Autoregulation Testing: Intact may need CPP to 70 mm Hg Mannitol/Hypertonic Saline ICP Management: Draining CSF and Providing Sedation/Analgesia Normothermia Tertiary Interventions Mild Hypothermia Decompressive Hemicraniectomy Barbiturate Coma Not used much in US Coordinated Care Clinical Guidelines Teamwork Family Focused Care Teamwork Putting It All Together Real World Real Patients The healthcare team can impact patients outcome by actively engaging families in care: Family Focused Care Providing FFC requires assessment, planning, intervention, and evaluations for each unique family Assurance, Proximity to Patient, Information, Comfort and Support 7

8 Teamwork: MD Protocols Teamwork: MD Protocols Teamwork Primary Interventions: Airway Assessment of Oxygenation/Ventilation Patency of airway Intervene: Rapid Sequence Intubation Oxygenation Ventilation 1 st 24 hours: PaCO mm Hg If Increased ICP PaCO mm Hg Influence of Airway/Ventilation Issues Day 1 Pulmonary worsens with PaO2 131 to 54 PbtO2 24 drops to 11 mm Hg ICP 35 mm Hg PbtO2 8 mm Hg Low PbtO2 correlating with low PaO2 Leads to Inc ICP Teamwork Primary Interventions: Circulation Optimize CPP: Find the right place Goal mm Hg Fluids: SVV < 13% Vasopressor support once euvolemic Interventions: Circulation Neck midline Head of Bed Flat if hypovolemic temporary measure 30 degrees if euvolemic 8

9 Primary Intervention: Intracranial Pressure CSF Drainage Normal range 0-15 mm Hg Abnormal ranges > 20 mm Hg Compliance waveform analysis Analgesia Fentanyl Sedation Propofol Teamwork Primary Intervention: Optimal Sedation /Analgesia Benzodiazepines Dexmedetomidine Teamwork Primary Intervention Step-Wise Management of Shivering Normothermia & Shivering Teamwork Secondary/Tertiary Interventions Secondary Interventions HTS Mannitol Tertiary Interventions Pentobarb coma Decompressive hemicraniectomy Mild Hypothermia Bundles Interventions: Systemic Infection prevention Ventilator Foley Central Line GI: OG for gastric decompression Stress ulcer prophylaxis Nutrition: caloric goal by day3 9

10 Interventions: Mobility Musculoskeletal Early Mobility Program START HERE MOVEN SCREEN Perform initial mobility screen within 8 hrs of ICU admission AND reassess every 12 hours Report at MDR daily (RN, RT, PT) Refer to the following criteria in determining mobility level: M: Myocardial stability 50 < HR* < < SBP* < < MAP* < 120 *or normal range for pt No active ischemia x 24 hrs No new IV antidysrhythmic agents x 24 hrs O: Oxygenation FiO2 60% PEEP < 12 SPO2 92% (88% with activity) 10 < RR < 35 V: Vasopressor(s) minimal No increase in vasopressor infusion in last 2 hrs E: Engages to voice Pt opens eyes to verbal stimulation N: Neurologic stability ICP <20mmHg Absence of active seizures x 24hrs CONTRAINDICATIONS: Unstable fx Active bleeding Active fluid resuscitation Open chest/abdomen Tolerates Level I Tolerates Level II Tolerates Level III Tolerates Level IV activities, progress activities, progress activities, progress activities, progress to to Level II. to Level III to Level IV. Level V. Includes complex, intubated, hemodynamically unstable and Includes intubated, non-intubated and hemodynamically stable intubated patients; may include non-intubated. stable/stabilizing, no contraindications. LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V RASS -5 TO RASS -3 AND RASS -1 AND UP RASS 0 AND UP RASS 0 AND -3 UP UP Goal: Passive ROM; Goal: Upright sitting; Goal: Increased trunk Goal: Stand with assist; Goal: Increase Initiate nutrition within Increased strength; strength; Move legs against March in place and ambulation distance 24 hrs Move arms against gravity and readiness to transfer to chair gravity weight bear; Ability to perform some ADL s with assist Activity: Activity: Activity: Activity: Activity: HOB 30 o Full chair position Self or assisted turning Active transfer OOB to OOB to chair Passive ROM 3x/day 3x/day x 30 min Q 2hr chair with RN, PT, OT 3x/day with RN, by RN, PCT or family Passive ROM Sitting EOB with RN, PT, 3x/day x 30 min (meal PCT, PT, OT x 60 Turn Q 2hr 3x/day by RN, PCT OT x 15 min time) min or family Full chair position Sitting on EOB/stand Ambulate determined by PT) Turn Q 2hr 3x/day x min at bedside with RN, progressively Begin transfer to chair PT, OT longer distances 2- Dietician Consult determined by PT) via Sabina lift Self or assisted 3x/day with RN, PT Consult for cycle Passive ROM/begin to turning Q 2hr PCT, PT, OT ergometry and family PT Consult if not encourage AAROM Full chair position Cycle ergometry education board already following 3x/day by RN, PCT or 3x/day x 60 min (as determined by recommendations OT Consult PRN family Encourage PT) ST Consult for coma (i.e., neuro, splinting AAROM/AROM stim and family needs) determined by PT) 3x/day with RN, PCT, education board SP Consult if pt has PT, OT or family recommendations trach OT Consult SP Consult if extubated determined by PT) Begin Family Education and not already Board following ARU Consult ARU Consult (if consistently participating with therapy and able to follow commands) *For each position/activity change, allow 5-10 min for equilibration before determining the patient is intolerant. **If the patient is intolerant of current activity level, reassess and place in appropriate mobility level. MDR: Multidisciplinary Rounds EOB: Edge of Bed PROM: Passive Range of Motion AAROM: Active-Assisted Range of Motion AROM: Active Range of Motion ADL s: Activities of Daily Living Levels Levels I-II-III Guidelines for Early Mobility Complex, intubated, hemodynamically unstable and stable intubated patients May include non-intubated Levels III-IV-V Intubated, non-intubated and hemodynamically stable/stabilizing, no contraindications. For each position/activity change, allow 5-10 min for equilibration before determining the patient is intolerant. If the patient is intolerant of current activity level, reassess and place in appropriate mobility level. LEVEL I RASS -5 TO -3 Goal: Passive ROM; Initiate nutrition within 24 hrs Activity: HOB 30 o Passive ROM 3x/day by RN, PCT or family Turn Q 2hr determined by PT) Dietician Consult PT Consult for cycle ergometry and family education board recommendations ST Consult for coma stim and family education board recommendations Begin Family Education Board Tolerates Level I activities, progress to Level II. RASS -5 to -3 Level I LEVEL II RASS -3 AND UP Goal: Upright sitting; Increased strength; Move arms against gravity Activity: Full chair position 3x/day x 30 min Passive ROM 3x/day by RN, PCT or family Turn Q 2hr determined by PT) PT Consult if not already following OT Consult PRN (i.e., neuro, splinting needs) SP Consult if pt has trach Level II RASS -3 and UP LEVEL III RASS -1 AND UP Goal: Increased trunk strength; Move legs against gravity and readiness to weight bear; Ability to perform some ADL s with assist Activity: Self or assisted turning Q 2hr Sitting EOB with RN, PT, OT x 15 min Full chair position 3x/day x min Begin transfer to chair via Sabina lift Passive ROM/begin to encourage AAROM 3x/day by RN, PCT or family determined by PT) OT Consult SP Consult if extubated and not already following ARU Consult (if consistently participating with therapy and able to follow commands) Level III RASS -1 and UP Tolerates Level II activities, progress to Level III Tolerates Level III activities, progress to Level IV. 10

11 LEVEL IV LEVEL V RASS 0 AND UP RASS 0 AND UP Goal: Stand with assist; Goal: Increase March in place and ambulation distance transfer to chair Activity: Activity: Active transfer OOB to OOB to chair chair with RN, PT, OT 3x/day with RN, 3x/day x 30 min (meal PCT, PT, OT x 60 time) min Sitting on EOB/stand Ambulate at bedside with RN, progressively PT, OT longer distances 2- Self or assisted 3x/day with RN, turning Q 2hr PCT, PT, OT Full chair position Cycle ergometry 3x/day x 60 min (as determined by Encourage PT) AAROM/AROM 3x/day with RN, PCT, PT, OT or family determined by PT) ARU Consult Tolerates Level IV activities, progress to Level V. Levels IV and V RASS 0 and UP P = Physiologic Changes from TBI R = Resuscitation O = Operative Intervention T = Technology E = Entry to ICU C = Coordinated Care/Clinical Guidelines T = Teamwork & Family Centered Care Nursing Strategies for Neuro PROTECT - ION I Individualize Care! O Outcomes must be measured and analyzed! N Nuances: What have you learned as a team? Individualize Care Each patient is unique! Responses to injury vary Outcome Measurement in TBI Case Overview Case Study 30 year old male involved in altercation falls backwards/strikes head Arrival in ED as a Trauma GCS 3 with fixed non-reactive pupils at 5 mm bilateral Intubated with 7.5 ET/Foley/OG IV Mannitol 100 grams IV 11

12 11/26/2014 4/6/1983 4/6/1983 BRAIN BRAIN WO WO ST ST 11/15/ /15/2013 6:52:40 PM PM C T T BRAIN T BRA IN WO S ST 11/15/2013 6:52:37 PM C T LOC : LOC LOC : CT Operating Room 18.76mm 18.76mm Preop Diagnosis RD : 217 R D: Tilt: -8-8 ma: ma : KVp: K Vp: Acq A cq No: 22 Page: 13 of 217 C ompressed ompressed 11:1 11:1 Jakishev, Jakishev, Amirzhan Amirzhan A AR AR A A CT C T Brain Brain MIssion MIssion AS64 AS64 Head ontrast Head wo wo C Contrast Acq Acq No: No: 2 2 BRAIN BRAIN WO WO ST ST 4/6/1983 4/6/ /15/2013 6:52:37 PM PM C C T T mm AR /6/1983 C T Brain Head wo wo C ontrast ontrast BRAIN WO ST 11/15/ /15/2013 6:52:38 6:52:38 PM PM C T T C T LOC :: LOC LOC:: LOC : LOC: ma: KVp: Acq No: No: 2 Page: Page: of of Jakishev, Amirzhan A AR Procedure Evacuation of L SDH Left craniectomy Placement of ICP/PbtO2 EBL: 1 liter RD: RD : RD: RD: Tilt: Tilt: -8 ma: ma : KV p: 120 KVp: 120 Acq Acq No: No: 2 Left Subdural Hematoma Sagittal suture diastasis C ompressed 11:1 Compressed 11:1 A MIssion AS64 C T Brain Head wo wo C ontrast ontrast BRAIN WO WO ST ST H45s H45s 11/17/2013 5:00:45 5:00:45 AM AM C T T To SICU C T T LOC : LOC :: Arrived 2230 Transported on 100% from OR Page: 30 of 211 C ompressed 11:1 11/17/ /17/2013 5:00:46 5:00:46 AM CT C T LOC : LOC: MAP 93 ICP 10 = CPP 82 PbtO2 50 PaCO2 42 PaO2 379 FIO2 titrated down to 50% within 1 hour LOC LOC : RD: Tilt: -14 ma: ma: KVp: KV p: Acq Acq No: 3 Page: Page: 20 of of PP C ompressed 11:1 IM: IM: SE: S E: 3 Day 3: Assessment for MOVEN SICU Day 1-2 Safety Screening (Patient must meet all criteria) ICP 10 to low 20s MAP 75 ICP PbtO mm Hg Tx Hypertonic Saline Pupillary reaction improving CS mm/sec in R CS mm /sec in L MOVEN SCREEN Refer to the following criteria in determining mobility level: MAP Pt intubated/ventilated Sedated RASS -4 ICP CPP Versed & Fentanyl ICP requiring drainage Assessed for MOVEN PbtO2 R CV L CV Improvement if goes in this direction Phase I Ready for ergometry evaluation M: Myocardial stability 50 < HR* < < SBP* < < MAP* < 120 *or normal range for pt No active ischemia x 24 hrs No new IV antidysrhythmic agents x 24 hrs O: Oxygenation FiO2 60% PEEP < 12 SPO2 92% (88% with activity) 10 < RR < 35 V: Vasopressor(s) minimal No increase in vasopressor infusion in last 2 hrs E: Engages to voice OR Pt opens eyes to verbal stimulation N: Neurologic stability ICP <20mmHg Absence of active seizures x 24hrs CONTRAINDICATIONS: Unstable fx Active bleeding Active fluid resuscitation Open chest/abdomen 12

13 Focused Mobility with Team Day 4 Before Ergometry ICU Course Days 3-7 ICP After 20 minutes into Ergometry PbtO2 ICP ICP controlled with periodic spikes above 20 PbtO2 range mm Hg PbtO2 Before Ergometry Day 5 Mobility Notes PT Day 6 ICP PbtO2 After 20 minutes into Ergometry ICP PbtO2 Weaning sedation ICP controlled / VS stable Continues with ergometry Days 6-8 Nurse Note Day 7 Nurse Note Day 8 PT Note Day 10 13

14 LEVEL II RASS -3 AND UP Goal: Upright sitting; Increased strength; Move arms against gravity Progress from Level I to II PT Note Day 11 Activity: Full chair position 3x/day x 30 min Passive ROM 3x/day by RN, PCT or family Turn Q 2hr determined by PT) PT Consult if not already following OT Consult PRN (i.e., neuro, splinting needs) SP Consult if pt has trach Tolerates Level II activities, progress to Level III Weaning sedation ICP controlled / VS stable Day 10 ICP & PbtO2 D/C Weaned from Vent 1 st extubation Day 8 fail due to secretions 2 nd extubation Day 13 Continues with ergometery Days Nurse Note Day 10 Nurse Note Day 14 LEVEL III RASS -1 AND UP Goal: Increased trunk strength; Move legs against gravity and readiness to weight bear; Ability to perform some ADL s with assist Activity: Self or assisted turning Q 2hr Sitting EOB with RN, PT, OT x 15 min Full chair position 3x/day x min Begin transfer to chair via Sabina lift Passive ROM/begin to encourage AAROM 3x/day by RN, PCT or family determined by PT) OT Consult SP Consult if extubated and not already following ARU Consult (if consistently participating with therapy and able to follow commands) Days 14 Level III Tolerates Level III activities, progress to Level IV. Days PT Note Day 23 Progress with strengthening but has ++ secretions GCS improves from 3-5-1T on Day 14 to 4-6-1T by Day 25 Increasing interaction with family and nurses PT/OT/ST working with patient 2x per day each service 14

15 LEVEL IV LEVEL V RASS 0 AND UP RASS 0 AND UP Goal: Stand with assist; Goal: Increase March in place and ambulation distance transfer to chair Activity: Activity: Active transfer OOB to OOB to chair chair with RN, PT, OT 3x/day with RN, 3x/day x 30 min (meal PCT, PT, OT x 60 time) min Sitting on EOB/stand Ambulate at bedside with RN, progressively PT, OT longer distances 2- Self or assisted 3x/day with RN, turning Q 2hr PCT, PT, OT Full chair position Cycle ergometry 3x/day x 60 min (as determined by Encourage PT) AAROM/AROM 3x/day with RN, PCT, PT, OT or family determined by PT) ARU Consult Progressing Level IV-V Pt has no insurance Case Manager working on arrangements for ARU for 4 weeks (Began working on case early in hospital stay) 1 month Nurse Note Day 30 Nurse Note Day 34 Nurse Note Day 40 Tolerates Level IV activities, progress to Level V. Outcomes Transferred to PCSU on Day 43 Admitted to ARU on Day 53 By Day 61: independent in bed mobility, improved transfer, able to walk 150 ft with supervision/contact guard assist; ADLs supervised; cognition overall moderate assist Cranioplasty completed on Day 61 Complicated by EDH develop Post op day 1- return to OR for evacuation Transferred to ARU Day 68 to complete ARU Discharge home on Day 76 Ambulating 175 feet; ADLs supervised; Cognition minimal assist for attention to task; Problem solving min assist level Conclusion 15