Brain under pressure Managing ICP. Giuseppe
|
|
- Randolf Ellis
- 6 years ago
- Views:
Transcription
1 Brain under pressure Managing ICP Giuseppe
2 Intro Thresholds Treating HICP Conclusions NO COI for this presentation
3 Produces pressure gradients: herniation HIGH ICP Reduces CBF Negative impact on outcome
4 Level I and II A The new insufficient evidence There was insufficient evidence to support a Level I or II A recommendation for this topic. Level II B Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2016
5 Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care. Intensive Care Med Aug 20. Recommendation ICP and CPP monitoring are recommended as a part of protocol-driven care in patients who are at risk of elevated intracranial pressure based on clinical and/or imaging features. (Strong recommendation, moderate quality of evidence.)
6 GCS 8 and CT abnormalities Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233
7 American Heart Association/American Stroke Association ICP monitoring should be undertaken in patients with more severe SAH (WFNS 3), and that a ventricular catheter should be used as the ICP monitoring device because it offers the possibility of therapeutic draining of CSF to treat hydrocephalus Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 43(6),
8 International prospective observational StudY on intracranial PreSsurE in intensive care (ICU) The SYNAPSE-ICU Study ClinicalTrials.gov Identifier: NCT
9 Primary Injury Age Pre-injury health, Genetic factors Biological Response Progressive damage Secondary Insults Secondary Damage High ICP, low CPP, seizures, fever Final Outcome
10 Primary Injury Age Pre-injury health, Genetic factors Progressive damage Counteracting secondary Insults ICU monitoring Biological Response Reduce secondary damage Final Outcome
11 Intro Thresholds Treating HICP Conclusions
12 Historical thresholds (with Rx) <20
13 Probability Probability Why are we using 20mmHg? Good outcome Veg/Death % ICP>20 mmhg % ICP>20 mmhg Marmarou A, Anderson R, Ward J, Choi S, Young H, Eisenberg H, Foulkes M, Marshall L, Jane J. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. Special Supplements 1991; 75: 59 66
14 Lost in clinical translation Marmarou TCDB Simplistic interpretation Beyond age, admission motor score and pupils, the proportion of lcp measurements >20 mmhg is most indicative of outcome 20 mmhg is the threshold for starting therapy BTF till the 3 rd Treatment should be initiated with ICP thresholds above 20mmHg (Level II)
15 Sorrentino E, Diedler J, Kasprowicz M, Budohoski KP, Haubrich C, Smielewski P, Outtrim JG, Manktelow A, Hutchinson PJ, Pickard JD, Menon DK, Czosnyka M. Critical Thresholds for Cerebrovascular Reactivity After Traumatic Brain Injury. Neurocrit Care 2011;
16 Level II B 22 is the new 20 Treating ICP above 22 mm Hg is recommended because values above this level are associated with increased mortality. Carney, N., Totten, A. M., OʼReilly, C., Ullman, J. S., Hawryluk, G. W. J., Bell, M. J., et al. (2016). Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery,
17 Are these two patients really different? A B 40 ICP 40 ICP Therapy No therapy
18 A B 40 ICP 40 ICP mabp 70 mabp Which is the sickest patients?
19 15-19 micp micp Badri, S., Chen, J., Barber, J., Temkin, N. R., Dikmen, S. S., Chesnut, R. M., Deem, S., et al. (2012). Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Medicine, 38(11), doi: /s
20 ICP Dose Vik A et al. (2008) Relationship of dose of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 109:
21 Kaplan Meier survival curve of patients with asah stratified according to levels of PTDICP20 Magni F, Pozzi M, Rota M, Vargiolu A, Citerio G. High-Resolution Intracranial Pressure Burden and Outcome in Subarachnoid Hemorrhage. Stroke 2015; 46:
22 Güiza, F., Depreitere, B., Piper, I., Citerio, G., Chambers, I., Jones, P. A., et al. (2015). Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury. Intensive Care Medicine, ICP time burden Intensity*Time Adults Ped
23 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233
24 Intro Thresholds Treating HICP Conclusions
25 1965 Continuous recording of the ventricular-fluid pressure in eases of severe traumatic injury of the head facilitates the evaluation of intracranial dynamics and offers a more rational basis for treatment than do conventional control measures. Lundberg N, Troupp H, Lorin H. Continuous recording of the ventricular-fluid pressure in patients with severe acute traumatic brain injury. A preliminary report. J Neurosurg 1965; 22:
26 Level I and II A The new insufficient evidence There was insufficient evidence to support a Level I or II A recommendation for this topic. Level II B Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2016
27 Odds ratios of neurological outcomes at 1 year, comparing intracranial pressure (ICP) patterns SD/V versus GR/MD D versus GR/MD D versus all other outcomes Normal ICP Raised but reducible ICP Refractory ICP Glasgow Outcome Score: GR, Good Recovery; MD, Moderate Disability; SD, Severe Disability; V, Vegetative; D, Death Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review. Treggiari. Neurocrit Care (2007) 6:
28 Stocchetti, Carbonara, Citerio Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:
29 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:
30 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:
31 Sedation Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233
32 ICP target If ICP >20-25 mmhg If ICP controlled > 24 hrs Continue sedation Add therapy for HICP Re-evaluate the case/icp therapy intensive level Evaluate ceeg for titrating the dose Test withdrawal if successful: stop sedation if unsuccessful: restart sedation
33 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:
34 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233
35 Hyperosmolar fluids for the management of elevated ICP in neurocritical care patients Are available hyperosmolar fluids effective in reducing ICP? Hyperosmolar fluids (MAN, HTS, HTL) are effective in reducing ICP. GRADE: low quality evidence. Is there any evidence that hyperosmolar fluids have different efficacy (more or less effective) in reducing ICP? Studies were too heterogeneous to be combined in an overall body of evidence.
36 Mannitol HS
37 ICP REDUCTION mmhg ICP reduction after mannitol (low correlation) ICP REDUCTION mmhg ICP reduction after hypertonic saline (low correlation) Mannitol and HS for ICP treatment in TBI - Metaregression 35 Intercept = Q = Intercept = slope = p = 7.4e 09 Q = I 2 = 0 95% CI: 0 69 slope = I 2 = p = 1.496e 12 95% CI: Initial ICP mmhg INITIAL ICP mmhg Initial ICP mmhg
38 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:
39 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233
40 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233
41 STAGE 1 Mechanical ventilation Sedation Analgesia with or without paralysis Head of bed elevated to 30 degrees. Intravenous fluids with or without inotropes for MAP > 80 mm Hg. Opt: Ventriculostomy with or without CSF drainage. Opt: Surgical removal of space-occupying lesions Control Group Stage 2: Add Mannitol, Hypertonic saline, Inotropes to maintain cerebral perfusion pressure >60 mmhg Intracranial pressure >20 mmhg 5min within 10 days after injury Hypothermia Group Add stage 2 treatments only if needed Continued medical care. Barbiturate therapy with processed EEG monitoring. Decompressive craniectomy. Further surgical intervention if required Continued medical care. Barbiturate therapy with processed EEG monitoring. Decompressive craniectomy. Further surgical intervention if required Andrews, P. J. D., et al. (2015). Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England Journal of Medicine, 373(25),
42 Andrews, P. J. D., Sinclair, H. L., Rodriguez, A., Harris, B. A., Battison, C. G., Rhodes, J. K. J., et al. (2015). Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England Journal of Medicine, 373(25),
43 The adjusted common odds ratio for the GOS-E score was 1.53 (95% confidence interval, 1.02 to 2.30; P=0.04), indicating a worse outcome in the hypothermia group than in the control group. A favourable outcome (GOS-E score of 5 to 8, indicating moderate disability or good recovery) occurred in 26% of the patients in the hypothermia group and in 37% of the patients in the control group (P=0.03). Andrews, P. J. D., Sinclair, H. L., Rodriguez, A., Harris, B. A., Battison, C. G., Rhodes, J. K. J., et al. (2015). Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England Journal of Medicine, 373(25),
44 Implication for clinical practice NO HT in patients with intracranial hypertension that can be managed with stage 1 and 2 medical treatments. In patients with TBI who have severe intracranial hypertension, i.e., an ICP refractory to all stage 2 treatments before initiation of HT, the use of therapeutic HT when few alternatives remain, may be the single potential remaining indication for HT.
45 ICP > 20 mmhg, 15 minutes/1hr, despite optimized first-tier interventions. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med 2011;:
46 Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med 2011;:
47 Stage 1 Initial treatment measures Ventilation Sedation Analgesia ± Paralysis Nurse head up Monitoring CVP ICP>25 mmhg Stage 2 OPTIONS: Ventriculostomy Inotropes Mannitol Hypertonic saline Loop diuretics Steroids Hypothermia 34-36ºC BARBITURATES NOT PERMITTED ICP>25 mmhg 1-12 hours post start stage 2 RESCUEicp Trial Arterial line ICP Continued Medical treatment * (stage 2 options) + barbiturates permitted Decompressive craniectomy** + continued medical treatment (stage 2 options) Medical 4-6 h Surgical Stage 3 Randomise *If continued medical treatment is drawn no decompressive surgery will be performed at that time. However, decompressive surgery may be performed later if the patient deteriorates with an ICP > 40mmHg and compromised CPP Hutchinson PJ, RESCUEicp **If decompressive Trial Collaborators. craniectomy is Trial drawn of barbiturates Decompressive should Craniectomy not be administrated for Traumatic at that time. Intracranial However, Hypertension. barbiturates may N Engl J Med 2016; 375: be given later if the patient deteriorates with an ICP > 40mmHg and compromised CPP
48 6 months 12 months Hutchinson PJ, RESCUEicp Trial Collaborators. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 2016; 375:
49 For every 100 patients treated with DC rather than medical intent, 22 more survivors (CI 95% 13-31) C I 95% Vegetative Lower SD Upper SD Lower MD Lower GR 3 1-6
50
51 Intro Thresholds Treating HICP Conclusions
52 Take home messages High ICP is associated with negative outcome and has to be treated Thresholds need to keep in consideration intensity and time of exposure Therapies need to be order accordingly to tehr risk/benefit ratio Extreme therapies need to be limited to sicker patients
Perioperative Management of Traumatic Brain Injury. C. Werner
Perioperative Management of Traumatic Brain Injury C. Werner Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical
More informationTraumatic Brain Injury:
Traumatic Brain Injury: Changes in Management Across the Spectrum of Age and Time Omaha 2018 Trauma Symposium June 15, 2018 Gail T. Tominaga, M.D., F.A.C.S. Scripps Memorial Hospital La Jolla Outline Background
More information11. Traumatic brain injury. Links between ICP, CPP, PRx monitoring and outcome after TBI. Does CT picture help in prediction of outcome?
11. Traumatic brain injury. Links between ICP, CPP, PRx monitoring and outcome after TBI. Does CT picture help in prediction of outcome? Critical levels of CPP, ICP and PRx Percentage of patients in outcome
More informationCase 1. Case 5/30/2013. Traumatic Brain Injury : Review, Update, and Controversies
Case 1 Traumatic Brain Injury : Review, Update, and Controversies Shirley I. Stiver MD, PhD 32 year old male s/p high speed MVA Difficult extrication Intubated at scene Case BP 75 systolic / palp GCS 3
More informationPRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8
PRACTICE GUIDELINE Effective Date: 9-1-2012 Manual Reference: Deaconess Trauma Services TITLE: TRAUMATIC BRAIN INJURY GUIDELINE OBJECTIVE: To provide practice management guidelines for traumatic brain
More informationMoron General Hospital Ciego de Avila Cuba. Department of Neurological Surgery
Moron General Hospital Ciego de Avila Cuba Department of Neurological Surgery Early decompressive craniectomy in severe head injury with intracranial hypertension Angel J. Lacerda MD PhD, Daisy Abreu MD,
More informationStandardize comprehensive care of the patient with severe traumatic brain injury
Trauma Center Practice Management Guideline Iowa Methodist Medical Center Des Moines Management of Patients with Severe Traumatic Brain Injury (GCS < 9) ADULT Practice Management Guideline Contact: Trauma
More informationWhat is elevated ICP?
What is elevated ICP? and When should it be treated? David Menon Professor of Anaesthesia, University of Cambridge ICP monitoring recommended to reduce inhospital & 2-wk mortality Rx ICP > 22 mm Hg as
More informationAny closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand
Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand Evidence Pathophysiology Why? Management Non-degenerative, Non-congenital insult
More informationSevere traumatic brain injury. Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre
Severe traumatic brain injury Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre Primary focus of care Prevent ischemia, hypoxia and hypoglycemia Nutrient & oxygen supply Limited
More informationUpdate on Guidelines for Traumatic Brain Injury
Update on Guidelines for Traumatic Brain Injury Current TBI Guidelines Shirley I. Stiver MD, PhD Department of Neurosurgery Guidelines for the management of traumatic brain injury Journal of Neurotrauma
More informationPressure reactivity: Relationship between ICP and arterial blood pressure (ABP). Pressure-reactivity index, computational methods. Clinical examples.
Pressure reactivity: Relationship between ICP and arterial blood pressure (ABP). Pressure-reactivity index, computational methods. Clinical examples. Optimization of cerebral perfusion pressure: Relationship
More informationMedical Management of Intracranial Hypertension. Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center
Medical Management of Intracranial Hypertension Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center Anatomic and Physiologic Principles Intracranial compartments Brain 80% (1,400
More informationTraumatic Brain Injuries
Traumatic Brain Injuries Scott P. Sherry, MS, PA-C, FCCM Assistant Professor Department of Surgery Division of Trauma, Critical Care and Acute Care Surgery DISCLOSURES Nothing to disclose Discussion of
More informationUAMS MEDICAL CENTER TRAUMA and CRITICAL CARE SERVICES MANUAL. SUPERSEDES: New PAGE: 1 of 5. RECOMMENDATION(S): Drs. Bill Beck/J.R.
SUPERSEDES: New PAGE: 1 of 5 Purpose: To provide recommendations for the treatment and management of patients with traumatic brain injury. Definitions: Severe TBI - Glasgow Coma Scale (GCS) of 3 to 8 without
More informationICP. A Stepwise Approach. Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System
ICP A Stepwise Approach Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System ICP: Basic Concepts Monroe-Kellie doctrine: skull = fixed volume
More informationChapter 8: Cerebral protection Stephen Lo
Chapter 8: Cerebral protection Stephen Lo Introduction There will be a variety of neurological pathologies that you will see within the intensive care. The purpose of this chapter is not to cover all neurological
More informationImproving TBI outcome
Improving TBI outcome Dr Peter Smielewski ps10011@cam.ac.uk 20/10/2017 Division of Neurosurgery, Department of Clinical Neurosciences Background Stein, S. C., Georgoff, P., et al. (2010). Journal of Neurotrauma
More informationDecompressive craniectomy following traumatic brain injury
Decompressive craniectomy following traumatic brain injury Peter Hutchinson Division of Academic Neurosurgery University of Cambridge Escalating cycle of brain swelling Primary insult Brain swelling Secondary
More informationTraumatic Brain Injury Pathways for Adult ED Patients Being Admitted to Trauma Service
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
More informationContinuous cerebral autoregulation monitoring
Continuous cerebral autoregulation monitoring Dr Peter Smielewski ps10011@cam.ac.uk 20/10/2017 Division of Neurosurgery, Department of Clinical Neurosciences Determinants of cerebral blood flow Thanks
More informationTraumatic Brain Injury Pathway, GCS 15 Closed head injury
Traumatic Brain Injury Pathway, GCS 15 Closed head injury Plus Any One of the Following Mild TBI 2010 Consensus Definition of TBI from CDC, NINDS, NIDDR, VA, DVBIC, DCoE Plus Any One of the Following New
More informationLinee guida sul trauma cranico: sempre attuali? Leonardo Bussolin AOU Meyer
Linee guida sul trauma cranico: sempre attuali? Leonardo Bussolin AOU Meyer Vavilala MS, et al Retrospective multicenter cohort study Prehospital Arena ED OR - ICU Each 1% increase in adherence was associated
More information12/4/2017. Disclosure. Educational Objectives. Has been consultant for Bard, Chiesi
Temperature Management in Neuro ICU Kiwon Lee, MD, FACP, FAHA, FCCM Professor of Neurology, RWJ Medical School Chief of Neurology, RWJ University Hospital Director, RWJ Comprehensive Stroke Center Director,
More informationIntroduction to Neurosurgical Subspecialties:
Introduction to Neurosurgical Subspecialties: Trauma and Critical Care Neurosurgery Brian L. Hoh, MD 1, Gregory J. Zipfel, MD 2 and Stacey Q. Wolfe, MD 3 1 University of Florida, 2 Washington University,
More informationManagement of Traumatic Brain Injury (and other neurosurgical emergencies)
Management of Traumatic Brain Injury (and other neurosurgical emergencies) Laurel Moore, M.D. University of Michigan 22 nd Annual Review February 7, 2019 Greetings from Michigan! Objectives for Today s
More informationNeuroprotective Effects for TBI. Craig Williamson, MD
Neuroprotective Effects for TBI Craig Williamson, MD Neuroprotection in Traumatic Brain Injury Craig Williamson Clinical Assistant Professor Neurocritical Care Fellowship Director Disclosures I will discuss
More informationNeurointensive Care of Aneurysmal Subarachnoid Hemorrhage. Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA
Neurointensive Care of Aneurysmal Subarachnoid Hemorrhage Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA The traditional view: asah is a bad disease Pre-hospital mortality
More informationCerebral autoregulation is a complex intrinsic control. Time course for autoregulation recovery following severe traumatic brain injury
J Neurosurg 111:695 700, 2009 Time course for autoregulation recovery following severe traumatic brain injury Clinical article Gi l l E. Sv i r i, M.D., M.Sc., 1 Ru n e Aa s l i d, Ph.D., 2 Co l l e e
More informationSubarachnoid hemorrhage secondary to intracranial aneurysmal
High-Resolution Intracranial Pressure Burden and Outcome in Subarachnoid Hemorrhage Federico Magni, MD*; Matteo Pozzi, MD*; Matteo Rota, PhD; Alessia Vargiolu, PhD; Giuseppe Citerio, MD Background and
More informationTraumatic brain Injury- An open eye approach
Traumatic brain Injury- An open eye approach Dr. Sunit Dr Sunit, Apollo children's hospital Blah blah Lots of head injury Lot of ill children Various methods of injury Various mechanisms of brain damage
More informationexcellence in care Procedure Neuroprotection For Review Aug 2015
Neuro Projection HELI.CLI.14 Purpose This procedure outlines the management principles of patients being retrieved with traumatic brain injury (TBI), spontaneous intracranial haemorrhage (including subarachnoid
More informationSupplementary Online Content
Supplementary Online Content Cooper DJ, Nichol A, Bailey M, et al. Effect of early sustained prophylactic hypothermia on neurologic outcomes among patients with severe traumatic brain injury: the POLAR
More information11/27/2017. Stroke Management in the Neurocritical Care Unit. Conflict of interest. Karel Fuentes MD Medical Director of Neurocritical Care
Stroke Management in the Neurocritical Care Unit Karel Fuentes MD Medical Director of Neurocritical Care Conflict of interest None Introduction Reperfusion therapy remains the mainstay in the treatment
More informationRole of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases
31 Original Article Indian Journal of Neurotrauma (IJNT) 2006, Vol. 3, No. 1, pp. 31-36 Role of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases Deepak Kumar Gupta
More informationHEAD INJURY. Dept Neurosurgery
HEAD INJURY Dept Neurosurgery INTRODUCTION PATHOPHYSIOLOGY CLINICAL CLASSIFICATION MANAGEMENT - INVESTIGATIONS - TREATMENT INTRODUCTION Most head injuries are due to an impact between the head and another
More informationSurgical Management of Stroke Brandon Evans, MD Department of Neurosurgery
Surgical Management of Stroke Brandon Evans, MD Department of Neurosurgery 2 Stroke Stroke kills almost 130,000 Americans each year. - Third cause of all deaths in Arkansas. - Death Rate is highest in
More informationA Study to Describe Cerebral Perfusion Pressure Optimization Practice among ICU Patients of Tertiary Hospital of South India
International Journal of Caring Sciences January-April 2018 Volume 11 Issue 1 Page 296 Original Article A Study to Describe Cerebral Perfusion Pressure Optimization Practice among ICU Patients of Tertiary
More information11/23/2015. Disclosures. Stroke Management in the Neurocritical Care Unit. Karel Fuentes MD Medical Director of Neurocritical Care.
Stroke Management in the Neurocritical Care Unit Karel Fuentes MD Medical Director of Neurocritical Care Disclosures I have no relevant commercial relationships to disclose, and my presentations will not
More informationState of the Art Multimodal Monitoring
State of the Art Multimodal Monitoring Baptist Neurological Institute Mohamad Chmayssani, MD Disclosures I have no financial relationships to disclose with makers of the products here discussed. Outline
More informationPrecision Medicine in Neurocritical Care: Should we individualize care?
Precision Medicine in Neurocritical Care: Should we individualize care? Victoria McCredie Toronto Western Hospital Critical Care Canada Forum 2 nd November 2016 Conflicts of interest None Outline 1. Precision
More information8/29/2011. Brain Injury Incidence: 200/100,000. Prehospital Brain Injury Mortality Incidence: 20/100,000
Traumatic Brain Injury Almario G. Jabson MD Section Of Neurosurgery Asian Hospital And Medical Center Brain Injury Incidence: 200/100,000 Prehospital Brain Injury Mortality Incidence: 20/100,000 Hospital
More informationA BS TR AC T. n engl j med 367;26 nejm.org december 27,
The new england journal of medicine established in 1812 december 27, 2012 vol. 367 no. 26 A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury Randall M. Chesnut, M.D., Nancy Temkin, Ph.D.,
More informationINCREASED INTRACRANIAL PRESSURE
INCREASED INTRACRANIAL PRESSURE Sheba Medical Center, Acute Medicine Department Irene Frantzis P-Year student SGUL 2013 Normal Values Normal intracranial volume: 1700 ml Volume of brain: 1200-1400 ml CSF:
More informationRecent trends in the management of head injury
Recent trends in the management of head injury Contents: Current concepts of management in TBI Blood pressure and oxygenation Intracranial pressure monitoring Cerebral perfusion pressure Body temperature
More informationTHREE HUNDRED AND ten TBI patients with a
Acute Medicine & Surgery 2014; 1: 31 36 doi: 10.1002/ams2.5 Original Article Outcome prediction model for severe traumatic brain injury Jiro Iba, 1 Osamu Tasaki, 2 Tomohito Hirao, 2 Tomoyoshi Mohri, 3
More informationTraumatic brain injury (TBI) remains a lethal injury. Marked reduction in mortality in patients with severe traumatic brain injury.
J Neurosurg 119:1583 1590, 2013 AANS, 2013 Marked reduction in mortality in patients with severe traumatic brain injury Clinical article Linda M. Gerber, Ph.D., 1 Ya-Lin Chiu, M.S., 1 Nancy Carney, Ph.D.,
More informationCEREBRAL DECONGESTANTS. Dr. Dwarakanath Srinivas Additional Professor Neurosurgery, NIMHANS
CEREBRAL DECONGESTANTS Dr. Dwarakanath Srinivas Additional Professor Neurosurgery, NIMHANS Cerebral Oedema Increase in brain water content above normal (80%) in response to primary brain insult. Intracranial
More information1st Turku Traumatic Brain Injury Symposium Turku, Finland, January 2014
The TBIcare decision support tool aid for the clinician Jyrki Lötjönen & Jussi Mattila, VTT Technical Research Centre of Finland Validation of the decision support tool Ari Katila University of Turku 1st
More informationConflict of Interest Disclosure J. Claude Hemphill III, MD,MAS. Difficult Diagnosis and Treatment: New Onset Obtundation
Difficult Diagnosis and Treatment: New Onset Obtundation J. Claude Hemphill III, MD, MAS Kenneth Rainin Chair in Neurocritical Care Professor of Neurology and Neurological Surgery University of California,
More informationPerioperative Management Of Extra-Ventricular Drains (EVD)
Perioperative Management Of Extra-Ventricular Drains (EVD) Dr. Vijay Tarnal MBBS, FRCA Clinical Assistant Professor Division of Neuroanesthesiology Division of Head & Neck Anesthesiology Michigan Medicine
More information12/1/2017. Disclosure. When I was invited to give a talk in Tokyo 2011 at the 4 th International. Hypothermia Symposium
Disclosure Different Levels of Hypothermia: Is Cooler Better? Nothing to disclose (wish I did) Absolutely no conflict of interest for this lecture Kiwon Lee, MD, FACP, FAHA, FCCM Vice Chairman of Neurology
More informationPACT module. Traumatic Brain Injury. Intensive Care Training Program Radboud University Medical Centre Nijmegen
PACT module Traumatic Brain Injury Intensive Care Training Program Radboud University Medical Centre Nijmegen Severe traumatic brain injury Leading cause of morbidity/mortality among young individuals
More informationMedicines Protocol HYPERTONIC SALINE 5%
Medicines Protocol HYPERTONIC SALINE 5% HYPERTONIC SALINE 5% v1.0 1/4 Protocol Details Version 1.0 Legal category POM Staff grades Registered Paramedic Registered Nurse Specialist Paramedic (Critical Care)
More informationNeurocritical Care Monitoring. Academic Half Day Critical Care Fellows
Neurocritical Care Monitoring Academic Half Day Critical Care Fellows Clinical Scenarios for CNS monitoring No Universally accepted Guidelines Traumatic Brain Injury Intracerebral Hemorrhage Subarachnoid
More informationMalignant Edema and Hemicraniectomy After Stroke
Malignant Edema and Hemicraniectomy After Stroke Sherri A. Braksick, MD March 29, 2017 No Financial Disclosures No Discussion of Off-Label Usage Objectives 1. Review the pathophysiology of edema after
More informationLate decompressive craniectomyafter traumatic brain injury: neurological outcome at 6 months after ICU discharge
Cianchi et al. Journal of Trauma Management & Outcomes 2012, 6:8 RESEARCH Open Access Late decompressive craniectomyafter traumatic brain injury: neurological outcome at 6 months after ICU discharge Giovanni
More informationReducing intracranial pressure in patients with traumatic brain injury
Reducing intracranial pressure in patients with traumatic brain injury Learn how to identify rising intracranial pressure early to promote appropriate interventions. By Cindy L. Zerfoss, MSN, RN, ACNP-CS
More informationDisclosures. Anesthesia for Endovascular Treatment of Acute Ischemic Stroke. Acute Ischemic Stroke. Acute Stroke = Medical Emergency!
Disclosures Anesthesia for Endovascular Treatment of Acute Ischemic Stroke I have nothing to disclose. Chanhung Lee MD, PhD Associate Professor Anesthesia and perioperative Care Acute Ischemic Stroke 780,000
More informationStroke & Neurovascular Center of New Jersey. Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center
Stroke & Neurovascular Center of New Jersey Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center Past, present and future Past, present and future Cerebral Blood Flow Past, present and future
More informationDecompressive Hemicraniectomy in Acute Neurological Diseases
Decompressive Hemicraniectomy in Acute Neurological Diseases Angela Crudele, MD 1 ; Syed Omar Shah, MD 1 ; Barak Bar, MD 1,2 Department of Neurology, Thomas Jefferson University, Philadelphia, PA, Department
More informationperfusion pressure: Definitions. Implication on management protocols. What happens when CPP is too low, and when it is too high? Non-invasive CPP?
7. Cerebral perfusion pressure: Definitions. Implication on management protocols. What happens when CPP is too low, and when it is too high? Non-invasive CPP? Douglas J. Miller Miller JD, Stanek A, Langfitt
More informationManagement of head injury in the intensive-care unit
Management of head injury in the intensive-care unit Keith Girling Key points Head injuries are common and have a major impact predominantly on young individuals. Key principles of head-injury management
More informationPostanesthesia Care of the Patient Suffering From Traumatic Brain Injury
Postanesthesia Care of the Patient Suffering From Traumatic Brain Injury By: Susan Letvak, PhD, RN Rick Hand, CRNA, DNSc Letvak, S. & Hand, R. (2003). Postanesthesia care of the traumatic brain injured
More informationabstract n engl j med 373;25 nejm.org December 17,
The new england journal of medicine established in 1812 December 17, 2015 vol. 373 no. 25 Hypothermia for Intracranial Hypertension after Traumatic Brain Injury Peter J.D. Andrews, M.D., M.B., Ch.B., H.
More informationCPPopt: matters to be solved before or by an RCT? Geert Meyfroidt, MD, PhD Intensive Care Medicine University Hospitals Leuven Belgium
CPPopt: matters to be solved before or by an RCT? Geert Meyfroidt, MD, PhD Intensive Care Medicine University Hospitals Leuven Belgium Financial disclosures Research Foundation, Flanders (senior clinical
More informationIschemia cerebrale dopo emorragia subaracnoidea Vasospasmo e altri nemici
Ischemia cerebrale dopo emorragia subaracnoidea Vasospasmo e altri nemici Nino Stocchetti Milan University Neuroscience ICU Ospedale Policlinico IRCCS Milano stocchet@policlinico.mi.it Macdonald RL et
More informationMannitol for Resuscitation in Acute Head Injury: Effects on Cerebral Perfusion and Osmolality
Original articles Mannitol for Resuscitation in Acute Head Injury: Effects on Cerebral Perfusion and Osmolality J. A. MYBURGH*, S. B. LEWIS *Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SOUTH
More informationEdinburgh Research Explorer
Edinburgh Research Explorer Hypothermia for Intracranial Hypertension after Traumatic Brain Injury Citation for published version: Andrews, PJD, Sinclair, HL, Rodriguez Carbonell, A, Harris, B, Battison,
More informationChanging Demographics in Death After Devastating Brain Injury
Changing Demographics in Death After Devastating Brain Injury Andreas H. Kramer MD MSc FRCPC Departments of Critical Care Medicine & Clinical Neurosciences Foothills Medical Center, University of Calgary
More informationPediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth. Objectives 11/7/2017
Pediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth Objectives 1. Be able to discuss brain anatomy and physiology as it applies to
More informationMultimodal monitoring to individualize care in TBI
Multimodal monitoring to individualize care in TBI Critical Care Canada Forum 2017 October 4 th, 2017 Donald Griesdale MD MPH Associate Professor Department of Anesthesiology, Pharmacology & Therapeutics
More informationMannitol versus Hypertonic Saline for Management of Elevated Intracranial Pressure Jerry Altshuler, PharmD; Diana Esaian, PharmD, BCPS
Mannitol versus Hypertonic Saline for Management of Elevated Intracranial Pressure Jerry Altshuler, PharmD; Diana Esaian, PharmD, BCPS The intracranial compartment consists of predominantly brain parenchyma
More information9/19/2011. Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center. Epidural Hematoma: Lens Shaped.
Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center Epidural Hematoma: Lens Shaped. 1 Epidural Hematoma Subdural Hematoma: Crescent-shaped Subdural Hematoma 2 Cerebral Contusion Cause of
More informationHead trauma is one of the leading causes of death
clinical article J Neurosurg Pediatr 16:508 514, 2015 Outcome of children with severe traumatic brain injury who are treated with decompressive craniectomy Maroun J. Mhanna, MD, MPH, 1 Wael El Mallah,
More informationPATHOPHYSIOLOGY OF ACUTE TRAUMATIC BRAIN INJURY. Dr Nick Taylor MBBS FACEM
PATHOPHYSIOLOGY OF ACUTE TRAUMATIC BRAIN INJURY Dr Nick Taylor MBBS FACEM The Monro Kellie Doctrine CPP= MAP-ICP PRIMARY DAMAGE TBI is a heterogeneous disorder Brain damage results from external forces,
More informationShobana Rajan, M.D. Associate staff Anesthesiologist, Cleveland Clinic, Cleveland, Ohio
Shobana Rajan, M.D. Associate staff Anesthesiologist, Cleveland Clinic, Cleveland, Ohio Shaheen Shaikh, M.D. Assistant Professor of Anesthesiology, University of Massachusetts Medical center, Worcester,
More informationPlenary Address: Medico-Legal Issues in Neuro-intensive Care
Plenary Address: Medico-Legal Issues in Neuro-intensive Care Dr Basil Matta Divisional Director, Emergency and Perioperative Care Cambridge University Hospitals NHS Foundation Trust Medico-Legal Issues
More information9/18/16. Management of Ischemic Stroke in the Intensive Care Unit. Outline. Introduction. Kyle B Walsh MD. Phases of Stroke Diagnosis and Treatment
Management of Ischemic Stroke in the Intensive Care Unit Kyle B Walsh MD Assistant Professor - UC Dept of Emergency Medicine Fellow Physician - Neurocritical Care, Stroke, Research Outline Why ICU care
More informationManagement of Traumatic Brain Injury. Olaide O. Ajayi, MD
Management of Traumatic Brain Injury Olaide O. Ajayi, MD Traumatic Brain Injury (TBI) A bump, blow or jolt to the head that disrupts the normal function of the brain 1 Mild: Brief change in mental status
More informationHead injuries. Severity of head injuries
Head injuries ED Teaching day 23 rd October Severity of head injuries Minor GCS 14-15 Must not have any of the following: Amnesia 10min Neurological sign or symptom Skull fracture (clinically or radiologically)
More informationGLYCEMIC CONTROL IN NEUROCRITICAL CARE PATIENTS
GLYCEMIC CONTROL IN NEUROCRITICAL CARE PATIENTS David Zygun MD MSc FRCPC Professor and Director Division of Critical Care Medicine University of Alberta Zone Clinical Department Head Critical Care Medicine,
More informationHow Low Should You Go? Management of Blood Pressure in Intracranial Hemorrhage
How Low Should You Go? Management of Blood Pressure in Intracranial Hemorrhage Rachael Scott, Pharm.D. PGY2 Critical Care Pharmacy Resident Pharmacy Grand Rounds August 21, 2018 2018 MFMER slide-1 Patient
More informationCerebral perfusion pressure management of severe diffuse head injury: Effect on brain compliance and intracranial pressure
Original Article Cerebral perfusion pressure management of severe diffuse head injury: Effect on brain compliance and intracranial pressure S. Pillai, S. S. Praharaj, G. S. U. Rao,* V. R. S. Kolluri Departments
More informationSAH READMISSIONS TO NCCU
SAH READMISSIONS TO NCCU Are they preventable? João Amaral Rebecca Gorf Critical Care Outreach Team - NHNN 2015 Total admissions to NCCU =862 Total SAH admitted to NCCU= 104 (93e) (12.0%) Total SAH readmissions=
More informationSUBJECT: Clinical Practice Guideline for the Management of Severe Traumatic Brain Injury
ASPIRUS WAUSAU HOSPITAL, INC. Passion for excellence. Compassion for people. Effective Date: December 1, 2005 Proposed By: Samuel Picone III, MD, Trauma Medical Director Approval and Dates: Dr. Bunch,
More informationNeurotrauma: The Place for Cooling
Neurotrauma: The Place for Cooling Cooling: to achieve hypothermia History, evidence, open questions Cooling: to achieve normothermia Evidence, open questions Cooling: Practical Aspects Hypothermia: History
More informationMarshall Scale for Head Trauma Mark C. Oswood, MD PhD Department of Radiology Hennepin County Medical Center, Minneapolis, MN
Marshall Scale for Head Trauma Mark C. Oswood, MD PhD Department of Radiology Hennepin County Medical Center, Minneapolis, MN History of Marshall scale Proposed by Marshall, et al in 1991 to classify head
More information10. Severe traumatic brain injury also see flow chart Appendix 5
10. Severe traumatic brain injury also see flow chart Appendix 5 Introduction Severe traumatic brain injury (TBI) is the leading cause of death in children in the UK, accounting for 15% of deaths in 1-15
More informationPediatric Head Trauma August 2016
PEDIATRIC HEAD TRAUMA AUGUST 2016 Pediatric Head Trauma August 2016 EDUCATION COMMITTEE PEER EDUCATION Quick Review of Pathophysiology of TBI Nuggets of knowledge to keep in mind with TBI Intracranial
More informationMichael Avant, M.D. The Children s Hospital of GHS
Michael Avant, M.D. The Children s Hospital of GHS OVERVIEW ER to ICU Transition Early Management Priorities the First 48 hours Organ System Support Complications THE FIRST 48 HOURS Communication Damage
More informationThe resistance to CSF outflow in hydrocephalus what it is and what it isn t.
The resistance to CSF outflow in hydrocephalus what it is and what it isn t. Davson et al 1970, The mechanism of drainage of CSF. Brain 93:665-8 1989, Copenhagen, Alfred Benzon Foundation CSf outflow is
More informationGuidelines and Beyond: Traumatic Brain Injury
Guidelines and Beyond: Traumatic Brain Injury Aimee Gowler, PharmD, BCCCP, BCPS Neuromedicine Critical Care Clinical Pharmacy Specialist UF Health Shands Disclosures I have no financial interests to disclose.
More informationTraumatic Brain Injury
Traumatic Brain Injury Mark J. Harris M.D. Associate Professor University of Utah Salt Lake City USA Overview In US HI responsible for 33% trauma deaths. Closed HI 80% Missile / Penetrating HI 20% Glasgow
More information11 th Annual Cerebrovascular Symposium 5/11-12/2017. Hypertonic Use D E R E K C L A R K
Hypertonic Use D E R E K C L A R K 1 Outline Types of hyperosmolar therapy Review Cerebral Na Physiology Differences between periphery and BBB Acute phase Subacute phase Chronic changes Hypertonic Saline
More informationA bs tr ac t. n engl j med 364;16 nejm.org april 21,
The new england journal of medicine established in 1812 april 21, 2011 vol. 364 no. 16 Decompressive Craniectomy in Diffuse Traumatic Brain Injury D. James Cooper, M.D., Jeffrey V. Rosenfeld, M.D., Lynnette
More informationStroke - Intracranial hemorrhage. Dr. Amitesh Aggarwal Associate Professor Department of Medicine
Stroke - Intracranial hemorrhage Dr. Amitesh Aggarwal Associate Professor Department of Medicine Etiology and pathogenesis ICH accounts for ~10% of all strokes 30 day mortality - 35 45% Incidence rates
More informationCosa chiedo all autoregolazione cerebrale?
Frank Update in Traumatologia Cranica FRANK A. RASULO ANESTHESIOLOGY, INTENSIVE CARE, PERIOPERATIVE CARE and PAIN MEDICINE Spedali Civili University Hospital Brescia, Italy Cosa chiedo all autoregolazione
More informationSevere Traumatic Brain Injury Protocol
Severe Traumatic Brain Injury Protocol PROTOCOL I. Objective II. Definition of Severe TBI III. Patient Care: Parameters IV. Patient Care: Management Timeline (First 7 days of TBI) V. Nursing Care: Communication
More informationThe management of severe traumatic brain injury
J Neurosurg 120:1451 1457, 2014 AANS, 2014 Pressure autoregulation monitoring and cerebral perfusion pressure target recommendation in patients with severe traumatic brain injury based on minute-by-minute
More information