measuring severity of tbi - neurosci.kku.ac.th nna51... · d5nss 900 cc, nss 3,500 cc, acetar 1,000...
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Assist. Prof.Savai NorasanFirst National Neuroscience Conference Biotec, March25, 1.00-3.00 pm
Traumatic Brain injury: TBI
� Affected younger people (15-35 yrs)� Male: female = 3-5: 1 (risk-taking behavior)
� Causes life long impairment in� Physical� Cognitive� Behavioral & social function� Social burden: family education & counseling
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�Primary brain damage –����������� ��������������������� ����� -�Cerebral concussion, Cerebral contusion, Cerebral laceration, Intracranial hemorrhage.
�Secondary brain damage-�� ���!�����"������#������� ����� � IICP, hypoxia, cerebral edema, hypotension
Measuring severity of TBI
� Glasgow coma scale with score (GCS)� $�%�����%�� &'���(��)���'
� �*����������+�'������',��*���� functional outcome
� Post traumatic Amnesia (PTA)� �*���� cognitive & functional deficit
Glasgow Coma Scale & score
� Glasgow Coma Scale� Eye opening
� Verbal response
�Motor response
� Glasgow Coma Score� Eye opening (scores 1-4)
� Verbal response (scores 1-5)
�Motor response (scores 1-6)
Glasgow coma scale/score
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Glasgow coma scale& neurological sheet
� Eye opening (scores 1-4)
� Verbal response (scores 1-5)
� Motor response (scores 1-6)
mild injuryGCS 15-13(80 %)
moderate injuryGCS 12-9(10 %)
severe injuryGCS 8-3(10 %)
GCS
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� +����� ��0 22 $2 �3��������� �+���� ��� � 30 ���� PTA �� �3��6+� ���!�� �3����#����$+���,��%��� �3
�����,� ���������������'���� 2 &�����+�'��"���������#�0 �,'��(�$7'�#����� ����#�������(������*��,8���� ��
� PE: GCS: E1V2M1, pupils slightly react to light, RE 3 mm, LE 5 mm.� Temp 37.2 9C, Pulse 102/min, RR 36 /min, BP 140/80 mmHg, star shape Laceration wound at Left parietal area ~ 2.5 Cm, active bleeding
� Deformity left forearm
� Intubate ET tube
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� CT brain� Bilateral subdural hematoma (SDH) with cerebral edema with small Intraventricular hemorrhage (IVH) at occipital horn,
� Left lateral ventricle mild hydrocephalus with epidural hematoma (EDH) at left parieto-occipital lobe
� Diffuse brain swelling, 1.4 cm. midline shift to left, transtentorial & tonsilar herniation
� Multiple skull and base of skull fracture and pneumocephalus with cerebral contusion at right temporal lobe
Day1Day1-- 17/12/4917/12/49
�� Operation Operation &������&������ 11 CraniectomyCraniectomy
�� IntraoperationIntraoperation�� HctHct 22 %22 %-- PRC 6 units, FFP 2 unitsPRC 6 units, FFP 2 units
�� BP drop BP drop –– drip drip DopaminDopamin (1:1) rate 5(1:1) rate 5--20 cc/hrs20 cc/hrs
�� Fluid replacementFluid replacement�� D5NSS 900 cc, NSS 3,500 cc, D5NSS 900 cc, NSS 3,500 cc, AcetarAcetar 1,000 cc, 1,000 cc, VoluvenVoluven500 cc500 cc
�� Op. time 4.30 hours.Op. time 4.30 hours.
�� Post op admit ICU 19 daysPost op admit ICU 19 days
Day 11-33
�� TracheostomyTracheostomy Day11,Day11, 28/12/4928/12/49
�� PercutaneousPercutaneous EndoscopicEndoscopic gastrostomygastrostomy (PEG) (PEG) Day 29, 15/1/50Day 29, 15/1/50
� CT brain: Day32, 18/1/50� Blood clot at bilateral, 3rd, 4th ventricle, foramen of Magendie, & foramen of Lushka, increase hydrocephalus
� Increase external brain herniation
�� 4. External Ventricular Drainage (EVD) 4. External Ventricular Drainage (EVD) Day33Day33, 19/1/50, 19/1/50
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Day45, 31/1/50-6/2/50
�� External Ventricular Drainage (EVD)External Ventricular Drainage (EVD)�� Temp 38-40 oC
� Over drainage content (CSF content ~250-1,000 CC/day)
� Flap 8$7�) Lumbar punctureLumbar puncture
� UA-13/2/50- WBC –TNTC,
� Urine culture-13/2/50- gram negative bacilli
Day70-91 27/2/50
� Ventriculo-peritoneal (VP) shunt- Day 70(shunt reservoir obstruction)
� Ventriculo-peritoneal (VP) shunt- Day71,28/2/50
� Remove VP shunt (cloudy yellow CSF, flap 8$7)– Day80, 9/3/50
� External Ventricular Drainage (EVD) (communicating hydrocephalus, yellowish CSF, slightly turbid)- Day87, 16/3/50
� External Ventricular Drainage (EVD) -(Yellowish CSF, slightly turbid)- Day91,20/3/50
Day96-115
� External Ventricular Drainage (EVD) -(Yellowish CSF, slightly turbid)- Day96,25/3/50
� External Ventricular Drainage (EVD) -(Yellowish CSF, slightly turbid)- Day106,4/4/50
� CT brain: Day115, 13/4/50� Multiple abscess at temporal lobe with meningitis, ventriculitis, obstructive hydrocephalus
� CSF culture – MRSA� Px. Vancomycin drip� Vancomycin level peak 39.72, through 19.7 $�� dose Vanco 500 mg IV q 8 hrs.
Day120-165
� External Ventricular Drainage (EVD) -Day120, 18/4/50
� CT brain- Day150, 18/5/50� Brain abscess with ventriculitis, meningitis,
� Increased brain swelling
� Obstructive hydrocephalus, right basal ganglia herniation
� CT brain- Day165, 2/6/50� Slightly decreased size of bilateral ventricle
� Severe degree of obstructive hydrocephalus
Day194-377
�Ventriculo-peritoneal (VP) shunt-Day194, 1/7/50
�Ventriculo-peritoneal (VP) shunt-Day204, 1/8/50
� CT brain- Day377, 29/12/50�Improve degree of obstructive hydrocephalus
28/1/51 (Day 408) ~21.50 �
� Temp 38-40 o C
� ����' #��"����,��� +�������'��� ~ 3 ����
� Intubate ET tube with ventilator
� Dilantin IV drip
� Blood culture-staph
� Lumbar puncture� WBC 24, PMN 52, Mono 40, RBC 50,000
� Prot 1200, sugar 79
� ATB- vancomycin
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Problem lists
� IICP- CraniectomyCraniectomy, CSF drainage, CSF drainage
�Ventriculitis
� Prolong ventilator
� Post traumatic seizure
� Persistent vegetative State (PVS)
� Family support/spouse coping & skills
Cycle of progressive brain swelling
Vasodilation
Cerebral blood volume
IICP
CPP
Arterial blood Pressure-spontaneous hypotension-Hypovolemia-Cardiogenic shock-Pharmacological
EdemaCSF
-Metabolic rate-Viscosity of blood-Hypoxia-Hypercarbia
Management of IICP
� Hemodynamic support� Respiratory management� Positioning� Osmotherapy:
� Osmotic agent, hypertonic saline
�Maintainance of normothermia�Surgery:
�CSF drainage, craniectomy
Hemodynamic support
� SBP > 90 mmHg� Mean arterial Pressure (MAP) ~ 70-80 mmHg� ICP< 15 mmHg. CPP > 60-80 mmHg.� Hematocrit ~ 30-33 %� If BP drop: Dopamine, dobutamine�� Maintain Maintain normovolemianormovolemia-- Avoid dehydrationAvoid dehydration�� 0.9 % NSS, 30.9 % NSS, 3% NSS
�� Do NOT use DDo NOT use D55W (W (increase brain edema increase brain edema �� Elevated blood sugar; increase global cerebral Elevated blood sugar; increase global cerebral ischemiaischemia
�� lactic acid, lowering tissue pHlactic acid, lowering tissue pH
Positioning in IICP
� �������� 30-45 ��� ������������������������������
� ��������� �� �� ����! venous return ���
� flat head if hypotension� �����.��/%�(����,����$�%8�+�? 3�� BP drop .. (..3�� Hypovolemic ...�%�*�"#� CPP ��� ��%�0��������� Cerebral Vasodilate �% IICP)
(Klein, 1999: 217)
Respiratory management
� Normocapnia
�� adequate oxygen, patent airway, and mechanical adequate oxygen, patent airway, and mechanical ventilationventilation
� Hyperventilation: benefit after 24 hours?? (Use for Use for ‘‘road tripsroad trips’’))� keep PaO2 > 70 mmHg
� keep PaCO2 30-35 mmHg (normal 35-45 mmHg)
� Increase CO2 ....Cerebral Vasodilation
� Decrease CO2 ...Cerebral Vasoconstriction
� PaO2 < = 40 mmHg…cerebral vasodilation
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Suctioning vs. IICP
� #����������� suction 3�� ICP> 20 mmHg, CPP< 70 mmHg.
� Aseptic tecnique, ��,&'�"�,������� 2 &��� �% �,�%&�����,&'�����',� 10 '����� &'���)����� ~ 15 cm. #�� 1/3 �&'����'����
� pressure 100-120 mmHg. �%&'��$C��D��%+,'����)����
� ��� suction&'������� 1/2 � ET tube/ Tracheostomy �%&'���#���E�( ����$F��� tracheal mucosal trauma.
� �,� �%#�� suction &'�"#� O2 100 % $�%��- 1 ����
(Cook, Int. Crit. Care. Nurs., (2003) 19, 143-153)
Respiratory problems
� �& 49 - �& 50 (Day1-227) "�,�&���+,'�#��"�� 2 �& 50- (Day228) T-piece� 5 �� 50 (Day 262) �$����� tracheos �$L� silver tube
� 25 �� 50 (Day 280) $C� tracheostomy� 29 �& 51- (Day 409) "�,�&���+,'�#��"�� 6 �� 51- (Day 417) Tracheostomy
� Wean Oxygen T-piece 15 L/min� 18 �� 51- room air, monitor O2 saturation
Pneumonia
� Postural drainage� �*�'���% 2 � ���� Left lower Lung
� �,� feed �#�� 1 +��'8��*� 5-10 ����
� ����.��/%�� #�0�#��"���%8��
� ��'�% &�)�&'�*� ����!����)��
OsmoticOsmotic agentagent
�� MannitolMannitol 20% (0.2520% (0.25--1 g/kg) 300 cc IV in 30 1 g/kg) 300 cc IV in 30 minutes, (prevent minutes, (prevent rebound effect)rebound effect)
� Reduce Hct. & blood viscosity.
� Increased CBF & cerebral O2 delivery.
� Enhance fluid loss & hypovolemia
�� Follow lab, serum osmolarity, serum Na/K
� Monitor dehydration signs: orthostatic hypotension, increase HR, CVP < 4, dry skin
Management of IICP
� Non osmotic agent
�Furosemide (Lasix) 20-40 mg IV� #��������$N��������*�"#������ ICP
� "�, PEEP> 5-10mmHg, � ���� ��� � ,� ����(� Tracheostomy tube �,������$� Excessive noise� Painful procedure� Unnecessary light� Unfamiliar environment
Nursing intervention VS IICP
� �%�%�'�� �%&'��3������"#������� �������,����$����� $��ICP
� ��,�����������',�&'��%�'�������������� ��%�� ����������3�*�����������
� �����-��D��%���
� Senses of comfort & reassurance� ����� ��� pt coma �� IICP ���
� �,3���� �� IICP ��,�� (N =30, response 25)
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Infection
�� MeningitisMeningitis�� Brain abscessBrain abscess�� VentriculitisVentriculitis� Treatment
� Sulperasone 3 gm IV q 12 hr� Vancomycin 1 gm IV q 6 hr� Tienam 500 mg IV q 8 hr� Meronam 2 gm IV q 8 hr� Augmentin 1.2 gm IV q 8 hr
Ventriculitis
� Incidence 40 % of EVD� Main source of infection
� Skin exit site� Connection between:
�Drain tube & ventricular catheter� Bag & drain
� Risk factors� Drain management� "�,��� > 4 '��
ExternalVentricular drainage
Nursing care for EVD
� $�� �%�� �0�#����� ��������/�$����(,�(����)����#(/��%#�,�#���$�%��- 10-15 !�.
� ��'�� �*� #�, �%�%�� ��0�#���0�&������������$������,�"#��(�$7'�#��$�� �%�� #�'����"#�, �%'���,"#� CSF �#����������$
� ��'� �% ���)�$����-� CSF �0��'�#����������,"#�����)���
� ��'�� ��,"#������#��/0��������� �%#',��&��������&'�#�� ����% ���������$F�������#������� �
����#�'�����(, Ventricle
� �OF��%'��������$���- ��%�� ��%�,�� !)�� & ��
External ventricular drainage
Ventriculostomy
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Ventricular peritoneal shunt
Post traumatic Seizure� 18/12/49-28/1/50
�Dilantin 250 mg + 0.9 % NSS 100 CC IV drip OD Elevate LFT�Dilantin 50 mg/tablet x 2 Tube feed� $�� Dilantin- Off 2/2/50
� 28/1/51 –focal & general tonic seizure�Dilantin 1,000 mg + 0.9 % NSS 100 cc IV drip in 1 hr
�Then drip 100 mg IV q 8 hr.-off 4/2/51
�Dilantin (50 mg/tablet) 2 tablets oral q 8 hr
� Lioresal ½ tablet x 3 pc.
Post traumatic Seizure
� Risk factors�GCS < 10
�Cortical contusion
�Depress skull fracture
�EDH, SDH, ICH
� Penetrating head wound
�Seizure within 24 hrs of injury
(Olson,S. (2004), Review of the role of anticonvulsant prophylaxisFollowing brain injury. J of Clinical Neuroscience, 11(1): 1-3)
Post traumatic Seizure� Classification
� Impact seizure (< 24 hrs after injury)
�Early seizure (<1 week after injury)
� Late seizure (> 8 days after injury)
(Olson, S. (2004). Review of the role of anticonvulsant prophylaxisFollowing brain injury. J of Clinical Neuroscience, 11(1): 1-3)
Antiepileptic drug� Phenytoin (Dilantin) IV
����"� 0.9 % NSS ��,�����
�IV #��� drip ���'���� 50 mg/minute
�Monitor Blood pressure, EKG�Side effect: skin rash, leukopenia, StevenJohnson syndrome, LFT �����, ataxia, vomiting, nystagmus, diplopia, drowsiness, gum hyperplasia
�Negative effects on cognition
(Olson, S. (2004). Review of the role of anticonvulsant prophylaxisFollowing brain injury. J of Clinical Neuroscience, 11(1): 1-3)
PhenytoinPhenytoin
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����,�����"#�Q������,'��,'�
� ��Q���� �(����#% � AMBU
� �*� passive exercise
� +,'��#��"�����*����'���$�%�*�'��
� �����'����*��#��$NR���� ���8�+�� �%��'���"#��#���������
� Blenderized diet (1:1) 400 cc X 4 fds� �'�$N���'% �%��"���-������,�����3$N���'%����
Consequence of TBI� Physical disability� Complication
�Pneumonia, DVT, pressure sore
� Complex neurological (Cognitive & behavioral) change
�Disrupt quality of life
Outcome indicators in severe TBI
�� Length of stay in ICULength of stay in ICU
�� Length of stay inLength of stay in hospitalhospital
�� Post injury day fed (target day 3)Post injury day fed (target day 3)
�� Post injury dayPost injury day tracheostomytracheostomyperformed (target day 4)performed (target day 4)
�� Number of ventilator daysNumber of ventilator days
�� Incidence of pneumoniaIncidence of pneumonia
Basic predictors outcome after TBI
� Age
� GCS
� Pupil reactivity
� Presence of major extracranial injury
Research issues related to biotechnology
� Monitoring: � IICP
� Partial pressure of brain tissue oxygenation (PbtO2)
� Behavioral & personal issue
� Antiepileptic drug & cognition
� Mechanism to enhance cognitive function � Neuroprotective strategies (IICP management)
� Neuroplasticity: Axon sprout
Research issues in TBI
� Medical complication� Social reintegration/Return to work � Caregiver coping skills� Psychosocial issues for spouse of TBIsurvivors� Increase responsibilities� Economic changes� Dealing with unpredictable behavior� New role as care giver