measuring severity of tbi - neurosci.kku.ac.th nna51... · d5nss 900 cc, nss 3,500 cc, acetar 1,000...

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1 Assist. Prof.Savai Norasan First 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 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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Page 1: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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

������������� ����� ��

�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

Page 2: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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

��-�.)�/�

� +����� ��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

��-�.)�/�1

� 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

Page 3: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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

Page 4: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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

Page 5: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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)

Page 6: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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

Page 7: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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

Page 8: Measuring severity of TBI - neurosci.kku.ac.th nna51... · D5NSS 900 cc, NSS 3,500 cc, Acetar 1,000 cc, Voluven 500 cc Op. time 4.30 hours. Post op admit ICU 19 days Day 11-33 Tracheostomy

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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