icp and cranial trauma
TRANSCRIPT
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Cranial Trauma
Gabriel C. Tender, MDAssistant Professor of Clinical Neurosurgery
Louisiana State University in New Orleans
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Patient #1
• Walked in the ER after being hit in the head• Initial GCS 14 – E4 V4 M6 (confused, but
could maintain conversation)• Started vomiting in the ER• In CT scan he lost consciousness and GCS
dropped to 9 – E2 V2 M5 (opening eyes to pain only, muttering sounds, localizing pain)
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Patient #1
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Patient #1
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Patient #2
• Involved in football accident• GCS 10 – E2 V3 M5• Localize pain on R, not moving L side as much
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Patient #2
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Patient #2
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Patient #3
• Involved in high-speed MVA• Sedated and intubated in the field • Initial GCS 7 before sedation – E1 V1 M5
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Patient #3
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Cranial Trauma
• What is the most important factor on physical examination?• Level of consciousness
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Cranial Trauma
• GCS stratification (max: E4 V5 M6)• 14-15 mild
• 9-12 moderate
• 3-8 severe• NB: A confused patient cannot have a GCS of 15 (verbal is
4, so his GCS is 14 at the most)
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Mild Head Injury
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Orders for minor/moderate CHI
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Mild Head Injury
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Moderate and Severe Head Injury
• What else is important (in comatose patients)?• Lateralization
• Blown pupil
• Different reaction to pain (left vs. right)
• Babinski on one side only
• Rectal tone if a spinal cord injury is suspected
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General Initial Assessment
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Exploratory Burrholes
• Indication (rare)• Patient dying of rapid transtentorial herniation
(ipsilateral blown pupil and/or contralateral paralysis or decerebration) not improved with mannitol and hyperventilation
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Exploratory Burrholes
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Head CT
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CT evaluation – midline shift
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CT evaluation – the basal cisterns
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Head CT
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Epidural Hematoma (EDH)
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Acute Subdural Hematoma (SDH)
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Parenchimal Lesions (Contusions)
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Posterior Fossa Lesions
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Cranial Fractures
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ICP Monitoring
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Insertion Point
• 13 cm from the nasion, or just behind the hair line
• 3 cm from the midline (usually on the right), or midpupillary line
• For ventriculostomies• Aim for the ipsilateral epicanthus to hit the frontal
horn, or go perpendicular to the bone (“straight down”) to hit the body of the lateral ventricle
• If you haven’t hit the ventricle by 5 cm, STOP! (you’re going in the wrong direction; pull out and choose a new direction)
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Ventriculostomy
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Ventriculostomy
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ICP monitors
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ICP monitors – Integra (Licox)
• Monitors both ICP and PaO2• Is more difficult to insert and maintain• Has more drift
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ICP monitors – Integra (Licox)
• Tricks for insertion• Use the drill that comes in the ICP monitor box, NOT the one in the cranial
access kit
• When you drill, put the drill stop at about 1.3-1.5 cm (you have to go through the bone)
• Make sure you puncture the dura
• Don’t tighten the second knob until you’re done inserting the monitors
• Take all the three stylets out before inserting the Camino fiberoptic ICP monitor
• You will feel some resistance when you go through the dura; gently overcome it
• Do not insert the monitor past the black dot• Once all three monitors are inserted, tighten the second knob
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ICP monitors – Codman
• Monitors ICP only• Is easy to insert and maintain• Has less drift
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ICP monitors – Codman
• Tricks for insertion• When you drill, put the drill stop at about 1.3-1.5 cm (you have
to go through the bone)
• Make sure you puncture the dura
• Zero with the monitor tip in sterile water
• Do not insert the monitor past 5 cm (put a black mark at 5 cm from the tip)
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When to treat increased ICP?
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Increased ICP Treatment - Hyperventilation
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Increased ICP Treatment - Hyperventilation
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Increased ICP Treatment - Mannitol
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No steroids for TBI!
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Barbiturate Coma
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ICP treatment
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ICP treatment
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Nutrition
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Posttraumatic Seizures
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MCLNO Clinical Neurophysiology Laboratories Electroencephalography, Evoked Potentials, Polysomnography
Medical Director Electrophysiologists Technologists
Bruce Fisch, MD Piotr Olejniczak, MD Tom Miller, REEGT
Edward Mader, MD Lisa KeppardJose Padin, MD Terri Ware
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IVF
• Do NOT use D5; use ½ NS w/ 20 KCl • Keep them euvolemic to dry (about 1cc/kg/hr)• If brain edema is an issue, keep serum Na
above 140• Mannitol and/or
• 3% saline (start at 15cc/hr, increase up to 50/hr)
• Check serum Na and osmol q6 hrs – do not exceed serum Na of 155 or serum osmol of 320
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Admit Orders for Severe CHI
• Admit to ICU• S/P TBI• Cond: critical• Vitals q1hr w/ neuro checks (if on Propofol, stop and check q4 hrs)• Bedrest, HOB to 30*, loosen c-collar when patient sedated• NPO• IVF
• ½ NS w/ 20 K @ 80-100 cc/hr• If significant brain edema, start 3%NS @ 15/hr, increase up to 50/hr (keep serum Na at 145-155, serum osmol 300-320)
• Vent• No or low PEEP• Keep PaCO2 at 30-35 (see hyperventilation above)
• Meds• Propofol drip or Ativan 2-10mg iv q1hr for sedation or ICP>20 for>5’• MSO4 2-10 mg iv q1hr prn pain or ICP>20 for>5’• Mannitol 25g iv q4hrs prn ICP>20 for>5’ (hold if serum Na >155 or osmol>320)• Cerebyx 1g iv now (loading dose), then 100mg q8• Pepcid 20mg iv bid• Ancef 1g iv q8 if scalp wound or ICP monitor
• Nursing – per ICU routine• Labs
• CBC, CMP, Dilantin level qAM• Serum Na and osmol q6 if on 3% NaCl or Mannitol
• Repeat head CT in am (at least 2 CTs per patient, one on arrival and one next day)• Call for problems
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Brain Death Exam in Adults
• Absence of brainstem reflexes• Fixed pupils• Absent corneal reflexes• Absent oculovestibular reflex (cold water calorics)• Absent oculocephalic reflex (not if C-spine not cleared)• Absent gag and cough reflex
• No response to deep central pain• Apnea test (last test to perform!)• Vital signs
• Core temp > 32.2*C (90*F)• SBP>90 mm Hg
• No drugs in the system!
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GSW to the Brain
• Immediate actions• Control bleeding from scalp• Shave scalp to identify entrance/exit wounds
• Assume ICP is elevated and treat• Start antibiotics• Obtain CT, rarely angio• Patients with GCS 3 and no hematoma
should usually not be operated upon
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GSW to the Brain - Goals of Surgery
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Summary
• On arrival, check• Level of consciousness (GCS)• Signs of lateralization
• Ipsilateral blown pupil• Contralateral hemiplegia• Unilateral Hoffman / Babinski
• CT scan• Size of the hematoma / contusions• Midline shift / effaced cisterns
• ICP monitor if GCS<8*• For decreasing GCS, time is of essence
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