Traumatic brain Injury- An open eye approach

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Aubrie Ryan
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1 Traumatic brain Injury- An open eye approach Dr. Sunit Dr Sunit, Apollo children's hospital

2 Blah blah Lots of head injury Lot of ill children Various methods of injury Various mechanisms of brain damage Various guidelines, management approaches

3 Guidelines for the acute management of severe traumatic brain injury in infants, children, and adolescents

4 Why is ICP monitoring required??? Secondary Injury Mechanisms Not all neurological damage from TBI occurs at the moment of impact!!!!

6 Evidence, evidence and more evidence ICP>20 predicts neurological deterioration independent of Cerebral Perfusion Pressure- Juul et al, J Neurosurg CPP<60 consistently predicts poor outcome and it is impossible to predict Cerebral Perfusion Pressure without knowing the ICP- Rosner et al J Trauma 1990; Robertson et al, Crit Care Med Empirically boosting CPP may easily cause more harm than good- excess CPP will increase the ICP and probably worsen outcomes

7 IS THERE enough EVIDENCE? No true randomized blinded controlled study has ever been done and will need an act of God to get done. Until then we rely on the above rationale and second/ third rate evidence

depends on titration of antihypertensive medication based on serial blood pressure

8 Treatment for DKA mainly depends on insulin infusion titrated to effect based on serial blood glucose and acidosis measurement Treatment for hypertensive emergency depends on titration of antihypertensive medication based on serial blood pressure measurement Then why not management of intracranial hypertension with serial ICP monitoring???

9 Why is ICP monitoring required??? CPP= MAP - ICP

11 Who Needs ICP Monitoring? Intra-cranial pressure monitoring (ICP) is appropriate in infants and children with severe traumatic brain injury (TBI) (Glasgow Coma [GCS] score 8) (O). The presence of open fontanels and/or sutures in an infant with severe TBI does not preclude the development of intracranial hypertension or negate the utility of ICP monitoring GCS < 8 and Abnormal CT scan Or Normal CT scan with -age > 40 -unilateral or bilateral posturing -systolic pressure < 90 mmhg Guidelines Level II

12 Treatment for intracranial hypertension, defined as pathological elevation in intracranial pressure, should begin at an ICP > 20 mm Hg. Interpretation and treatment of inc. ICP based on any ICP threshold should be corroborated by frequent clinical examination monitoring of physiologic variables & imaging Guidelines Level II

13 ICP monitoring- How? Intraventricular A small catheter is placed within the ventricular system (ventriculostomy); allows for CSF drainage. Subarachnoid Hollow bolt or screw into the subarachnoid space Epidural Small fiberoptic sensor into epidural space (between skull & dura) Intraparenchymal Small fiberoptic catheter into the white matter of brain tissue (parenchyma)

External Ventricular Drain- THE METHOD OF CHOICE Pros: 1. Allows therapeutic drainage of CSF 2. Inexpensive 3. Generally more reliable than the other methods (less prone to error). Cons: 1.

14 External Ventricular Drain- THE METHOD OF CHOICE Pros: 1. Allows therapeutic drainage of CSF 2. Inexpensive 3. Generally more reliable than the other methods (less prone to error). Cons: 1. Highest incidence of infection 2. Highest risk of procedural complications, esp. hemorrhage 3. Can be challenging to place in patients with cerebral edema, small ventricles and midline shift

15 Parenchymal monitor Pros: 1. Easy to place 2. Very low incidence of complications- both infection and hemorrhage Cons: 1. Cannot drain CSF 2. Prone to error (newer models better) 3. Expensive

16 In paediatric patients who require intracranial pressure monitoring, a ventricular catheter or an external strain gauge transducer or catheter tip pressure transducer device is an accurate and reliable method of monitoring ICP Ventricular cath. device most accurate, reliable, low cost + enables therapeutic (CSF) drainage. No report of meningitis ICP monitoring.» tip; positive > 7.5 days No level of evidence

17 Other benefits--- When transduced, the ICP waveform has 3 peaks - P1- Percussive wave from transmission of systolic BP peak from choroid plexus - P2- Tidal wave, measure of brain compliance - P3- Equivalent of dicrotic notch When P2>P1, brain compliance is poor

18 Why are WE hesitant?? Infection Haemorrhage Cost

19 GUIDELINE OBJECTIVE(S) To offer the possibility for uniformity of traumatic brain injury care, and conformity with the best standards of clinical practice. To evaluate different technology for intracranial pressure monitoring INTERVENTIONS AND PRACTICES CONSIDERED Use and placement of intracranial pressure monitoring devices: Fluid-coupled external strain gauges (ventricular, subarachnoic, subdural, or epidural), Fluidcoupled micro strain gauge catheter tip (ventricular), Fluid-coupled fiberoptic (ventricular), Pneumatic (ventricular, parenchymal, epidural), Micro strain gauge (parenchymal, subdural), Fiberoptic (parenchymal, subdural) MAJOR OUTCOMES CONSIDERED Pressure range, Acuracy and reliability, Maximum error, Cost, jjjjjjjjjjjj Complications Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. Intracranial pressure monitoring technology. J Neurotrauma 2007;24(Suppl 1):S45-S54. [41 references]

20 Summary In patients who receive ICP monitoring, a ventricular catheter connected to an external strain gauge transducer is the most accurate and cost effective method of monitoring ICP. Clinically significant infections or hemorrhage associated with ICP devices causing patient morbidity are rare and should not deter the decision to monitor ICP. Parenchymal transducer devices measure ICP similar to ventricular ICP pressure but have the potential for measurement differences due to the inability to recalibrate. These devices are advantageous when ventricular ICP is not obtained or if there is obstruction in the fluid couple. Subarachnoid or subdural fluid coupled devices and epidural ICP devices are currently less accurate

21 Wake up SID

23 THE IDIOT BOX STORY 18 MONTH OLD INQUISITIVE BOY LOC, ENT BLEED GCS NOTED AT REFERRING HOSPITAL A GCS 8-9 Maintaining airway Pupil's unequal posturing B RR 30/min AEBE No distress SaO2 94% RA C HR 130/min PPWF MAP 60 mmhg

24 WE HAVE HIM ALL SET COLLAR TUBED ARTERIAL LINE CENTRAL LINE CAPNOMETER CATHETERISED OROGASTRIC TUBE NEURO PROTECTIVE CARE NEURO IMMAGING

25 THE SCAN CT findings Hydrocephalus Severe cerebral oedema Intra ventricular bleed

26 EVD for hydrocephalus

27 Repeat imaging after 72 hr suggested decrease in hydrocephalus and EVD in situ. Weaned neuroprotective care, extubated the kid, clinically would have deteriorated, probably would have had a neuro event reintubation. ICP monitoring Increasing pressure Second tier therapy Continued ventilation Extubated after 5 days Discharged home, neurologicaly intact

29 YET ANOTHER IDIOT BOX STORY 3 YR Female child with H/O TV fall on head admitted with GCS 7-8. A B GCS 7-8 RR Maintaining airway breathing regular and spontaneous No siezures spo % pupiles BERTL AEBE clear No posturing Tone normal C Hr 84-90/min Relative bradycardia MAPS 60-65mmhg

30 WE HAVE HIM ALL SET AGAIN COLLAR TUBED ARTERIAL LINE CENTRAL LINE CAPNOMETER CATHETERISED OROGASTRIC TUBE NEUROPROTECTIVE CARE NEURO IMAGING

31 CT Brain suggestive of severe cerebral edema with hydrocephalus

33 Comparison between two different ways of Rx Routine management Neuroprotective measures 72 hrs ventilation(mini.) Repeat CT after hrs Supra normal BP to achieve targeted CPP, probably Noradrenaline infusion Probably Central line insertion Rx with ICP monitoring Nueroprotectve measures EVD Therapeutic drainage CPP targeted therapy with actual ICP Accepted normal MAP, so no noradrenalin, no central line Early extubation.

34 Benefits due to EVD Saved cost + other benefits Less ventilation days and related complications. Less days of hospitalization Avoided CVL and related complications

35 YET ANOTHER STORY 13 yr boy with history of trivial fall and loss of consciousness at home came unresponsive in the ER. Assessment was A B GCS 7-8/ 15 Unresponsive PBERTL No posturing No seizures RT sided hemi paresis C HR 88-90/min maps mmhg PPWF maint Airway RR min AEBE, Clear spo % RA

36 WE HAVE HIM ALL SET AGAIN COLLAR TUBED ARTERIAL LINE CENTRAL LINE CAPNOMETER CATHETERISED OROGASTRIC TUBE NEUROPROTECTIVE CARE NEURO IMAGING

37 The scan CT Brain suggestive of Left sided intraparenchymal and intraventricular bleed secondary to the AV malformation. cerebral edema, midline shift

39 Routine management Neuroprotective measures Repeat CT after hrs Could not have knowned the end point to wean care Probable secondary neuro event, probable reintubation and ventilation Rx using ICP monitoring Neuroprotective measures ICP Monitoring with intraparenchymal monitor CPP targeted therapy, needed nor adrenalin Escalation to second tier Gradual weaning on neuro care, extubated on 8 th day Discharging home

40 Take home message Target severe TBI treatment to CPP CPP= MAP ICP Technology for monitoring ICP is readily available and accessible.

PRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8

PRACTICE 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