management of closed head injury nicholas sadovnikoff, md, fccm refresher course in anesthesia and...

Management of Closed Head InjuryManagement of Closed Head Injury

Nicholas Sadovnikoff, MD, FCCMNicholas Sadovnikoff, MD, FCCM

Refresher Course in Anesthesia and Critical CareRefresher Course in Anesthesia and Critical Care

November 26, 2011November 26, 2011

Kuwait City, KuwaitKuwait City, Kuwait

Case StudyCase Study

16 year-old right-handed maleUnrestrained driver auto vs. tree (tree victorious) 12/25/99At scene: 40 minute extrication

in respiratory arrest intubated, IV access & circulation established

Transported to BWH ED

Case StudyCase StudyIn BWH ED: VS BP 140/86 HR 126 SpO2 – 100%

GCS – 6T

Plain films: lateral neck - OK CXR - OKpelvis - L sup and inf pubic rami fx, sacral fxT-spine, L-S spine series no vertebral injury

Abd/pel CT pubic rami fx, sacral fx

C-spine CT – no injury

The Glasgow Coma ScaleThe Glasgow Coma Scale

ScoreScore Eye OpeningEye Opening VerbalVerbal MotorMotor

11 NoneNone NoneNone FlaccidFlaccid

22 PainPain MoansMoans ExtendsExtends

33 VoiceVoice Garbled Garbled WordsWords

FlexesFlexes

44 SpontaneousSpontaneous ConfusedConfused WithdrawsWithdraws

55 OrientedOriented LocalizesLocalizes

66 Follows Follows commandscommands

Case StudyCase StudyIn BWH ED:

CT head: minimally displaced L temporal skull fxsmall L subdural hematoma with significant mass effectpunctate L cortical hemorrhages, lateral ventricular effacement, ? intraventricular blood

TBI – Epidemiology (2010)TBI – Epidemiology (2010)

• Each year, an estimated 1.7 million people in Each year, an estimated 1.7 million people in the US sustain a TBI annually. Of them:the US sustain a TBI annually. Of them:

–1.365 million, nearly 80%, are treated and 1.365 million, nearly 80%, are treated and released from an emergency department.released from an emergency department.

–275,000 are hospitalized, and275,000 are hospitalized, and–52,000 die, 73% at the scene or in the ED52,000 die, 73% at the scene or in the ED

Evidence-Based PracticeEvidence-Based Practice

• For many decades, management of severe For many decades, management of severe head trauma was tyrannized by anecdote and head trauma was tyrannized by anecdote and institutional or individual idiosyncrasyinstitutional or individual idiosyncrasy

• Regional disparities in care and outcomes Regional disparities in care and outcomes were abundantwere abundant

• Established effective therapies were not being Established effective therapies were not being utilized, whereas practices shown to be utilized, whereas practices shown to be ineffective or even harmful persistedineffective or even harmful persisted

Survey of 219 hospital intensive care units in 45 states that Survey of 219 hospital intensive care units in 45 states that treated patients with severe head injury.treated patients with severe head injury.

Centers %Centers %

Routine ICP monitoring (more in high volume centers) 28Routine ICP monitoring (more in high volume centers) 28

Hyperventilation and osmotic diuretics routinely usedHyperventilation and osmotic diuretics routinely used 83 83

Aiming for PaCOAiming for PaCO22 < 25 mm Hg < 25 mm Hg 29 29

Corticosteroids use more than half the time Corticosteroids use more than half the time 64 64

Crit Care Med 23: 560-567, 1995Crit Care Med 23: 560-567, 1995

HistoryHistory• 11 authors and 14 topics11 authors and 14 topics• 3 years of meetings3 years of meetings• Over 3000 articles reviewedOver 3000 articles reviewed• 11stst edition completed in 1995 edition completed in 1995• 22ndnd edition published in 2000 edition published in 2000• 33rdrd edition published in 2007 edition published in 2007

Funded and supported by theBrain Trauma Foundation (BTF)

American Association of Neurological Surgeons World Health Organization’s Committee on Neurotrauma

Congress of Neurological SurgeonsAANS/CNS Joint Section on Neurotrauma and Critical Care

GuideGuidelines for Management of Severe TBIlines for Management of Severe TBI

Objectives:Objectives:• STATE and DISSEMINATE the current scientificSTATE and DISSEMINATE the current scientific

evidence for the OPTIMAL management of TBI.evidence for the OPTIMAL management of TBI.• Highlight issues for further RESEARCH andHighlight issues for further RESEARCH and

CLINICAL TRIALS.CLINICAL TRIALS.• Improve OUTCOME.Improve OUTCOME.

Topics Topics

• Trauma systemsTrauma systems• Initial managementInitial management• Resuscitation of blood pressure and oxygenationResuscitation of blood pressure and oxygenation• Indications for ICP monitoringIndications for ICP monitoring• ICP treatment thresholdICP treatment threshold• ICP monitoring technologyICP monitoring technology• Cerebral perfusion pressureCerebral perfusion pressure

TopicsTopics

• HyperventilationHyperventilation• MannitolMannitol• IV fluidsIV fluids• BarbituratesBarbiturates• HypothermiaHypothermia• SteroidsSteroids• Nutrition Nutrition • Antiseizure prophylaxisAntiseizure prophylaxis• ICP treatment algorithmICP treatment algorithm

Guidelines for the ManagementGuidelines for the Managementof Severe Traumatic Brain Injuryof Severe Traumatic Brain Injury

Topics listTopics list• Electronic literature searchElectronic literature search• All relevant articles:All relevant articles:

– Screened for scientific and statistical validityScreened for scientific and statistical validity– Classified according to a three point scaleClassified according to a three point scale

• Class IClass I• Class IIClass II• Class IIIClass III

• Recommended ONLY what the literature supportsRecommended ONLY what the literature supports


Class IClass I• Prospective, randomized, controlled trialsProspective, randomized, controlled trials

Class IIClass II• Non-randomized, prospective controlled trialsNon-randomized, prospective controlled trials• Observational studiesObservational studies

Class IIIClass III• Case seriesCase series• Case reportsCase reports• Expert opinionExpert opinion

Guidelines for the ManagementGuidelines for the Managementof Severe Traumatic Brain Injury:of Severe Traumatic Brain Injury:

33rdrd edition changes edition changes

““Standards” became “Level I recommendations”Standards” became “Level I recommendations”• Class I evidenceClass I evidence

““Guidelines” became “Level II recommendations”Guidelines” became “Level II recommendations”• Class II evidenceClass II evidence

““Options” became “Level III recommendations”Options” became “Level III recommendations”• Class III evidenceClass III evidence


Level I recommendationsLevel I recommendations• Represent principles that reflect a Represent principles that reflect a highhigh degree degree

of clinical certaintyof clinical certainty

Level II recommendationsLevel II recommendations• Represent principles that reflect a Represent principles that reflect a moderatemoderate degree degree

of clinical certaintyof clinical certainty

Level III recommendationsLevel III recommendations• Represent principles for which there is Represent principles for which there is unclearunclear

clinical certaintyclinical certainty

Topics Topics

Blood pressure and oxygenationBlood pressure and oxygenation

Brain Trauma – It’s a two-way streetBrain Trauma – It’s a two-way street

• Failure to support the CNS renders remaining organ Failure to support the CNS renders remaining organ system support a futile exercise, butsystem support a futile exercise, but



• The first steps in supporting the brain actually The first steps in supporting the brain actually involve tending to the ABC’sinvolve tending to the ABC’s



• The first steps in supporting the brain actually The first steps in supporting the brain actually involve tending to the ABC’s, becauseinvolve tending to the ABC’s, because

• Hypotension and hypoxemia are the leading causes Hypotension and hypoxemia are the leading causes of of secondary injurysecondary injury

Secondary InjurySecondary Injury

• In the recent decades, medical research has In the recent decades, medical research has demonstrated that all brain damage does not occur demonstrated that all brain damage does not occur at the moment of impact, but evolves over the at the moment of impact, but evolves over the ensuing hours and days. This is referred to as ensuing hours and days. This is referred to as secondary injury.secondary injury.

• The injured brain is extremely vulnerable to The injured brain is extremely vulnerable to hypotension, hypoxia, and increased intracranial hypotension, hypoxia, and increased intracranial pressure which are causes of secondary injury.pressure which are causes of secondary injury.

McHugh GS et al. Prognostic value of secondary insults in traumatic brain

injury: results from the IMPACT study. J Neurotrauma. 2007;24(2):287.

• Prospective prehospital and E.R. study of 717 Prospective prehospital and E.R. study of 717 severe head injury patients in the Traumatic Coma severe head injury patients in the Traumatic Coma Data Bank.Data Bank.

• Hypotension (SBP < 90 mm Hg) occurred in 35%Hypotension (SBP < 90 mm Hg) occurred in 35%of patients and was associated with a two fold of patients and was associated with a two fold increase in mortality.increase in mortality.

J. Trauma 34:216-222, 1993J. Trauma 34:216-222, 1993

Resuscitation of Blood PressureResuscitation of Blood Pressure& Oxygenation& Oxygenation

Level II recommendationLevel II recommendation• Blood pressure should be monitored and hypotension Blood pressure should be monitored and hypotension

(systolic blood pressure < 90 mm Hg) avoided.(systolic blood pressure < 90 mm Hg) avoided.

Level III recommendationLevel III recommendation• Oxygenation should be monitored and hypoxemia Oxygenation should be monitored and hypoxemia

(PaO2 < 60 mm Hg or O2 saturation < 90%) avoided.(PaO2 < 60 mm Hg or O2 saturation < 90%) avoided.

Initial ManagementInitial Management

Don’t forget the c-spine!Don’t forget the c-spine!

Initial ManagementInitial Management

Don’t forget the c-spine!Don’t forget the c-spine!

5-7% of severe head trauma patients have a 5-7% of severe head trauma patients have a concomitant c-spine injuryconcomitant c-spine injury

This increases to 8-10% of patients whose head This increases to 8-10% of patients whose head injury is from a MVCinjury is from a MVC

Topics Topics

Indications for ICP monitoringIndications for ICP monitoring

ICP PhysiologyICP Physiology


• Intracranial Contents (normal)Intracranial Contents (normal)–Brain 80%Brain 80%–CSF 10%CSF 10%–Blood 10%Blood 10%



• Munro-Kellie Doctrine – the volume of the cranial Munro-Kellie Doctrine – the volume of the cranial contents is constant :contents is constant :

VVbrainbrain + V + VCSF CSF + V+ Vbloodblood (+ V (+ Vmassmass) = K) = K



• Munro-Kellie Doctrine – the volume of the cranial Munro-Kellie Doctrine – the volume of the cranial contents is constant :contents is constant :

VVbrainbrain + V + VCSF CSF + V+ Vbloodblood (+ V (+ Vmassmass) = K) = K• When brain injury occurs, brain expands, other When brain injury occurs, brain expands, other

components must diminish, or pressure will risecomponents must diminish, or pressure will rise


• CSFCSF–Formed in choroid plexusFormed in choroid plexus


• CSFCSF–Formed in choroid plexusFormed in choroid plexus–Normal cerebral complement ~150mlNormal cerebral complement ~150ml


• CSFCSF–Formed in choroid plexusFormed in choroid plexus–Normal cerebral complement ~150mlNormal cerebral complement ~150ml–Quantity produced 0.3 ml/kg/hr = ~500ml/dayQuantity produced 0.3 ml/kg/hr = ~500ml/day


• CSFCSF–Formed in choroid plexusFormed in choroid plexus–Normal cerebral complement ~150mlNormal cerebral complement ~150ml–Quantity produced 0.3 ml/kg/hr = ~500ml/dayQuantity produced 0.3 ml/kg/hr = ~500ml/day– Indifferent to ICPIndifferent to ICP


• CSFCSF–Formed in choroid plexusFormed in choroid plexus–Normal cerebral complement ~150mlNormal cerebral complement ~150ml–Quantity produced 0.3 ml/kg/hr = ~500ml/dayQuantity produced 0.3 ml/kg/hr = ~500ml/day– Indifferent to ICPIndifferent to ICP–Slight decrease with furosemide, acetazolamideSlight decrease with furosemide, acetazolamide


• CSFCSF–Formed in choroid plexusFormed in choroid plexus–Normal cerebral complement ~150mlNormal cerebral complement ~150ml–Quantity produced 0.3 ml/kg/hr = ~500ml/dayQuantity produced 0.3 ml/kg/hr = ~500ml/day– Indifferent to ICPIndifferent to ICP–Slight decrease with furosemide, acetazolamideSlight decrease with furosemide, acetazolamide–Drainage is only meaningful way to affect this Drainage is only meaningful way to affect this

intracerebral componentintracerebral component


• Intracranial pressure-volume curveIntracranial pressure-volume curve

Topics Topics

Indications for ICP monitoringIndications for ICP monitoring

• 207 severely head injured patients who had ICP monitoring and 207 severely head injured patients who had ICP monitoring and head CT scanshead CT scans

• Patients with a normal head CT had a 13% chance of ICP > 20 Patients with a normal head CT had a 13% chance of ICP > 20 mm Hgmm Hg

• Risk of intracranial hypertension (with normal CT) increased to Risk of intracranial hypertension (with normal CT) increased to 60% if two or more of the following were noted:60% if two or more of the following were noted:

– 1) Age over 40 years1) Age over 40 years– 2) SBP < 90 mm Hg2) SBP < 90 mm Hg– 3) motor posturing3) motor posturing

• Study 29 years old – ~4 generations of CT scanners agoStudy 29 years old – ~4 generations of CT scanners agoJ. Neurosurg 56: 650-659, 1982J. Neurosurg 56: 650-659, 1982

Indications for ICP MonitoringIndications for ICP Monitoring

Level II recommendationLevel II recommendation• ICP monitoring is appropriate in severe head injury ICP monitoring is appropriate in severe head injury

patients with an abnormal CT, or patients with an abnormal CT, or

Level III Level III recommendationrecommendation• a normal CT scan if 2 or more of the following are a normal CT scan if 2 or more of the following are

noted on admission:noted on admission:– SBP < 90 mm HgSBP < 90 mm Hg– Age > 40 yearsAge > 40 years– Uni-/Bilateral motor posturingUni-/Bilateral motor posturing

• Surveyed 34 academic trauma centers in the US (28 Surveyed 34 academic trauma centers in the US (28 Level I and 6 Level II)Level I and 6 Level II)

• Defined “aggressive” management centers as those Defined “aggressive” management centers as those where ICP monitors were placed in >50% of patients where ICP monitors were placed in >50% of patients with an initial GCS of <9 and and abnormal head CTwith an initial GCS of <9 and and abnormal head CT

• 11 centers “aggressive”, 20 “nonaggressive”11 centers “aggressive”, 20 “nonaggressive”• Mortality: 27% vs. 45% (p=.01)Mortality: 27% vs. 45% (p=.01)• No differences in outcome among survivorsNo differences in outcome among survivors

Intraventricular CatheterIntraventricular Catheter

Topics Topics

ICP treatment thresholdICP treatment threshold

• The ICP threshold that was most predictive of 6 month The ICP threshold that was most predictive of 6 month outcome was analyzed in 428 severely head injured patients.outcome was analyzed in 428 severely head injured patients.

• The proportion of hourly ICP reading greater than 20 mm Hg The proportion of hourly ICP reading greater than 20 mm Hg was a significant independent determinant of outcome.was a significant independent determinant of outcome.

J. Neurosurg 75:S59-S66, 1991J. Neurosurg 75:S59-S66, 1991

ICP Treatment ThresholdICP Treatment Threshold

Level II recommendationLevel II recommendation• Treatment should be initiated with intracranial Treatment should be initiated with intracranial

pressure (ICP) thresholds above 20 mm Hg. pressure (ICP) thresholds above 20 mm Hg.

Level III recommendationLevel III recommendation• A combination of ICP values, and clinical and brain A combination of ICP values, and clinical and brain

CT findings, should be used to determine the need CT findings, should be used to determine the need for treatment.for treatment.

Topics Topics

ICP monitoring technologyICP monitoring technology

ICP Monitoring TechnologyICP Monitoring Technology

Recommendation (no level)Recommendation (no level)• In the current state of technology, the ventricular In the current state of technology, the ventricular

catheter connected to an external strain gauge iscatheter connected to an external strain gauge isthe most accurate, low cost, and reliable methodthe most accurate, low cost, and reliable methodof monitoring ICP. It also allows therapeuticof monitoring ICP. It also allows therapeuticCSF drainage. CSF drainage.

• ICP transduction via fiberoptic or strain gauge ICP transduction via fiberoptic or strain gauge devices placed in ventricular catheters provide devices placed in ventricular catheters provide similar benefits but at a higher cost.similar benefits but at a higher cost.

Topics Topics

Cerebral perfusion pressureCerebral perfusion pressure

CPP PhysiologyCPP Physiology

• Cerebral blood volume – hard to measureCerebral blood volume – hard to measure• Cerebral blood flow – surrogate for volumeCerebral blood flow – surrogate for volume

– Also hard to measureAlso hard to measure• TCDTCD• Xenon scans – not commercially viableXenon scans – not commercially viable

• Cerebral perfusion pressureCerebral perfusion pressure– Easy to measure (MAP – ICP (or CVP))Easy to measure (MAP – ICP (or CVP))– Target of therapy – traditionally to maintain > 70mmHgTarget of therapy – traditionally to maintain > 70mmHg– Not rigorously validated as a therapeutic strategyNot rigorously validated as a therapeutic strategy

CPP Treatment StrategyCPP Treatment Strategy

• Where did the goal of a CPP of 70 come from?Where did the goal of a CPP of 70 come from?

CPP Treatment StrategyCPP Treatment StrategyWhere did the goal of a CPP of 70 come from?Where did the goal of a CPP of 70 come from?

Rosner and Becker 1984Rosner and Becker 1984

Cat percussive injury modelCat percussive injury model

Elimination of plateau waves at CPP > 70mmHgElimination of plateau waves at CPP > 70mmHg

Plateau waves (Lundberg A waves)

ICP

CPP

Vasodilation

CBV

Plateau waves – lethal cycle hypothesisPlateau waves – lethal cycle hypothesis

• 158 patients with GCS < 7 managed according to a158 patients with GCS < 7 managed according to aCPP protocol:CPP protocol:

– Maintain euvolemia (CVP 8-10 mm Hg)Maintain euvolemia (CVP 8-10 mm Hg)

– Ventriculostomy CSF drainage at 15 mm HgVentriculostomy CSF drainage at 15 mm Hg

– Systemic vasopressors to maintain CPP at least 70 mm HgSystemic vasopressors to maintain CPP at least 70 mm Hg

– Hyperventilation, barbiturates, hypothermia not used.Hyperventilation, barbiturates, hypothermia not used.

• Mortality 29% and 2% vegetative for entire group. Favorable Mortality 29% and 2% vegetative for entire group. Favorable outcome in GCS 3 of 35% ranging up to 75% for GCS 7.outcome in GCS 3 of 35% ranging up to 75% for GCS 7.

J. Neurosurg 83: 949-962, 1995J. Neurosurg 83: 949-962, 1995

• CPP targetsCPP targets– CPP > 70CPP > 70– ICP < 20ICP < 20– MAP > 90MAP > 90

• ICP targetsICP targets– CPPCPP > 50> 50– ICP < 20ICP < 20– MAP > 70MAP > 70

Comparison of CPP-targeted therapy with ICP-targeted therapy

Cerebral Perfusion PressureCerebral Perfusion Pressure

• Conclusions:Conclusions:– With ICP-targeted therapy, 2.4-fold greater risk of With ICP-targeted therapy, 2.4-fold greater risk of

“secondary ischemic insults” defined as jugular venous “secondary ischemic insults” defined as jugular venous desaturationsdesaturations

– No difference between the two groups in neurologic No difference between the two groups in neurologic outcomeoutcome

– 5-fold higher incidence of ARDS (3% vs. 15%) in CPP-5-fold higher incidence of ARDS (3% vs. 15%) in CPP-targeted grouptargeted group

– “…“…potential adverse effects of this management strategy potential adverse effects of this management strategy may offset these beneficial effects.”may offset these beneficial effects.”

Robertson et al, CCM 1999; 27:2086-2095


“...the critical threshold for CPP seems to be 60 rather than 70 mmHg.”

Marion DW (editorial) CCM 2002 30:7; 1671-1672


Level II recommendationLevel II recommendation

Aggressive attempts to maintain cerebral perfusion Aggressive attempts to maintain cerebral perfusion pressure (CPP) above 70 mm Hg with fluids and pressure (CPP) above 70 mm Hg with fluids and pressors should be avoided because of the risk of pressors should be avoided because of the risk of adult respiratory distress syndrome (ARDS).adult respiratory distress syndrome (ARDS).


Level III recommendationLevel III recommendation

CPP of <50 mm Hg should be avoided.

The CPP value to target lies within the range of 50-70 mm Hg. Patients with intact pressure autoregulation tolerate higher CPP values.

Ancillary monitoring of cerebral parameters that include blood flow, oxygenation, or metabolism facilitates CPP management.

What about jugular venous saturation or What about jugular venous saturation or brain tissue oxygenation monitoring?brain tissue oxygenation monitoring?

What about jugular venous saturation or What about jugular venous saturation or brain tissue oxygenation monitoring?brain tissue oxygenation monitoring?

Level III recommendationLevel III recommendation

Jugular venous saturation (<50%) or brain tissue Jugular venous saturation (<50%) or brain tissue oxygen tension (<15 mm Hg) are treatment oxygen tension (<15 mm Hg) are treatment thresholds.thresholds.

Jugular venous saturation or brain tissue oxygen Jugular venous saturation or brain tissue oxygen monitoring measure cerebral oxygenation.monitoring measure cerebral oxygenation.

TopicsTopics

HyperventilationHyperventilation


• Is hyperventilation an appropriate strategy in Is hyperventilation an appropriate strategy in management of intracranial hypertension?management of intracranial hypertension?

– Reliably lowers ICPReliably lowers ICP

• But…But…– Works by cerebral vasoconstrictionWorks by cerebral vasoconstriction– Fatigable phenomenonFatigable phenomenon– Doesn’t work in injured brainDoesn’t work in injured brain– Rebound phenomenonRebound phenomenon


Level I recommendationLevel I recommendation• In the absence of increased intracranial In the absence of increased intracranial

pressure (ICP), chronic prolonged pressure (ICP), chronic prolonged hyperventilation therapy (PaCOhyperventilation therapy (PaCO22 of 25 mm Hg of 25 mm Hg

or less) should be avoided after severe or less) should be avoided after severe traumatic brain injury (TBI).traumatic brain injury (TBI).


Level II recommendationLevel II recommendation• The use of prophylactic hyperventilation The use of prophylactic hyperventilation

(PaCO(PaCO22 < 35 mm Hg) therapy during the first 24 < 35 mm Hg) therapy during the first 24

hours after severe TBI should be avoided hours after severe TBI should be avoided because it can compromise cerebral perfusion because it can compromise cerebral perfusion during a time when cerebral blood flow (CBF) is during a time when cerebral blood flow (CBF) is reduced.reduced.


Level III recommendationLevel III recommendation • Hyperventilation therapy may be necessary for Hyperventilation therapy may be necessary for

brief periods when there is acute neurologic brief periods when there is acute neurologic deterioration, or for longer periods if there is deterioration, or for longer periods if there is intracranial hypertension refractory to sedation, intracranial hypertension refractory to sedation, paralysis, cerebrospinal fluid (CSF) drainage, paralysis, cerebrospinal fluid (CSF) drainage, and osmotic diuretics.and osmotic diuretics.

TopicsTopics

MannitolMannitol

MannitolMannitol

• AdvantagesAdvantages– Non-metabolized, osmotically active alcoholNon-metabolized, osmotically active alcohol– Lowers ICP by osmotic mechanismLowers ICP by osmotic mechanism– Hydroxyl radical scavengerHydroxyl radical scavenger

• But…But…– Osmotic effect only with intact blood-brain barrierOsmotic effect only with intact blood-brain barrier– May aggravate edema in injured brain tissueMay aggravate edema in injured brain tissue– Diuretic – leads to volume depletionDiuretic – leads to volume depletion– Hemodynamic instability at serum osmolality >~325Hemodynamic instability at serum osmolality >~325

MannitolMannitol

Level II recommendationLevel II recommendation• Mannitol is effective for control of raised intracranial Mannitol is effective for control of raised intracranial

pressure (ICP) at doses of 0.25 gm/kg to 1 g/kg pressure (ICP) at doses of 0.25 gm/kg to 1 g/kg body weight. Arterial hypotension (systolic blood body weight. Arterial hypotension (systolic blood pressure < 90 mm Hg) should be avoidedpressure < 90 mm Hg) should be avoided

Level III recommendationLevel III recommendation• Effective doses range from 0.25 - 1.0 gm/kgEffective doses range from 0.25 - 1.0 gm/kg

body weight.body weight.

MannitolMannitol

Level III recommendationLevel III recommendation• Restrict mannitol use prior to ICP monitoring to Restrict mannitol use prior to ICP monitoring to

patients with signs of transtentorial herniation or patients with signs of transtentorial herniation or progressive neurological deterioration not progressive neurological deterioration not attributable to extracranial causes.attributable to extracranial causes.

TopicsTopics

IV fluidsIV fluids

Original Article Saline or Albumin for Fluid Resuscitation in

Patients with Traumatic Brain Injury

The SAFE Study Investigators

N Engl J MedVolume 357(9):874-884

August 30, 2007

Kaplan-Meier Estimates of the Probability of Survival

The SAFE Study Investigators. N Engl J Med 2007;357:874-884

TopicsTopics

Barbiturates and propofolBarbiturates and propofol

Barbiturates and propofolBarbiturates and propofolLevel II recommendationLevel II recommendation• Prophylactic administration of barbiturates to induce Prophylactic administration of barbiturates to induce

burst suppression EEG is not recommended.burst suppression EEG is not recommended.

• High-dose barbiturate administration is High-dose barbiturate administration is recommended to control elevated ICP refractory to recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. maximum standard medical and surgical treatment. Hemodynamic stability is essential before and Hemodynamic stability is essential before and during barbiturate therapy.during barbiturate therapy.

Barbiturates and propofolBarbiturates and propofolLevel II recommendation (continued)Level II recommendation (continued)• Propofol is recommended for the control of ICP, but Propofol is recommended for the control of ICP, but

not for improvement in mortality or 6 month not for improvement in mortality or 6 month outcome. High-dose propofol can produce outcome. High-dose propofol can produce significant morbidity.significant morbidity.

TopicsTopics

• HypothermiaHypothermia

TopicsTopics

Steroids Steroids

CRASH = Corticosteroid Randomisation After Significant Head Injury

SteroidsSteroids

Level I recommendationLevel I recommendation• The use of steroids is not recommended for The use of steroids is not recommended for

improving outcome or reducing intracranial pressure improving outcome or reducing intracranial pressure in patients with severe head injury.in patients with severe head injury.

TopicsTopics

Nutrition Nutrition

NutritionNutrition

Head injury is associated with elevated catabolic state Head injury is associated with elevated catabolic state and nitrogen wastingand nitrogen wasting

Starvation aggravates this processStarvation aggravates this process

Literature of relatively poor quality, but trend favors Literature of relatively poor quality, but trend favors early institution of nutritionearly institution of nutrition

NutritionNutrition

Level II recommendationLevel II recommendation• Patients should be fed to attain full caloric Patients should be fed to attain full caloric

replacement by day 7 post-injury.replacement by day 7 post-injury.

TopicsTopics

Antiseizure prophylaxisAntiseizure prophylaxis

• 404 post traumatic head injury patients (GCS 3-10 and 404 post traumatic head injury patients (GCS 3-10 and abnormal head CT) randomized to treatment with phenytoin abnormal head CT) randomized to treatment with phenytoin or placebo for one year with a two year follow up.or placebo for one year with a two year follow up.

• In the first week after injury 4% of the patients receiving In the first week after injury 4% of the patients receiving phenytoin had seizures compared to 14% taking placebo.phenytoin had seizures compared to 14% taking placebo.

• After the first week there was no significant difference After the first week there was no significant difference between the rate of seizures in the two groups. between the rate of seizures in the two groups.

N. Engl. J. Med 323:497-502, 1990N. Engl. J. Med 323:497-502, 1990

Antiseizure ProphylaxisAntiseizure Prophylaxis

Level II recommendationLevel II recommendation• Prophylactic use of phenytoin or valproate is not Prophylactic use of phenytoin or valproate is not

recommended for preventing late posttraumatic recommended for preventing late posttraumatic seizures (PTS).seizures (PTS).

• Anticonvulsants are indicated to decrease the Anticonvulsants are indicated to decrease the incidence of early PTS (within 7 days of injury). incidence of early PTS (within 7 days of injury). However, early PTS is not associated with worse However, early PTS is not associated with worse outcomes.outcomes.


Admitted to 7D ICU

ICP monitor placed

ICP elevated, remained >35mmHg in spite of aggressivemanagement with mannitol, furosemide and hypertonic saline

To OR for decompressive craniectomy

XXXXXXX

Decompressive Craniectomy for TBIDecompressive Craniectomy for TBI

• Considered “salvage therapy” for refractory ICHConsidered “salvage therapy” for refractory ICH• Poor quality data regarding efficacyPoor quality data regarding efficacy• Encouraging pediatric trialEncouraging pediatric trial• Recent trial in Australia/NZ disappointingRecent trial in Australia/NZ disappointing• RESCUEicp (Randomized Evaluation of Surgery RESCUEicp (Randomized Evaluation of Surgery

with Craniectomy for Uncontrollable Elevation of with Craniectomy for Uncontrollable Elevation of Intracranial Pressure) trial currently enrolling Intracranial Pressure) trial currently enrolling

Intracranial Pressure before and after Randomization.

Cooper DJ et al. N Engl J Med 2011;364:1493-1502

Cumulative Proportions of Results on the Extended Glasgow Outcome Scale.

Cooper DJ et al. N Engl J Med 2011;364:1493-1502

Conclusions

• In adults with severe diffuse traumatic brain injury In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of decreased intracranial pressure and the length of stay in the ICU but was associated with more stay in the ICU but was associated with more unfavorable outcomes.unfavorable outcomes.


Postoperatively localizing with both upper extremities

Protracted ICU course complicated by MRSA pneumonia

Tracheostomy 1/8/00 V-P shunt 1/21/00

Recovered consciousness, speech. Discharged to rehab 1/29/00


Rehab x 2 months

Special school x 2 months

Fall 2000 restarted junior year of high school

Seen in pre-operative clinic 11/00 for minor GU procedure

No detectable cognitive deficit

Thank you for your attention…Thank you for your attention…

Thank you for your attention… Thank you for your attention…

and THANK YOU for your very warm welcome and THANK YOU for your very warm welcome to this wonderful country and medical to this wonderful country and medical

community!community!

management of closed head injury nicholas sadovnikoff, md, fccm refresher course in anesthesia and...

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