sagraves traumatic brain injury

8/11/2019 SAGRAVES Traumatic Brain Injury

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Scott G Sagraves, MDProfessor, UMKC

Trauma Medical Director, Saint Lukes Hospital


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No financial relationships creating a conflict ofinterest to report


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Define the anatomy and physiology ofTraumatic Brain Injury (TBI)

Explain the concept of the Monroe-KellieDoctrine

Interpret the Brain Trauma Foundationguidelines for EMS treatment of TBI


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Worldwide, TBI is the leading cause of death& permanent disability

Annually, >50,000 die

230,000 hospitalized

Trimodal age distribution; < 5, 15-24, > 70

50% mortality within the first TWO hours


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AIRWAY & C-spine Control

BREATHINGCIRCULATION & Bleeding Control

DISABILITY - Neurologic AssessmentEXPOSURE


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Transient respiratory arrest after TBI

Inability to protect airway with GCS 8

Early intubation for adequate ventilation andoxygenation*

Obtain a brief neurologic exam prior tosedation/intubation


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Pre-Hospital Intubation (PHI)is Associatedwith an Increased Mortality After TBI

2549 patients analyzed PHI vs. non-PHI Mortality 90.2% vs. 12.4%

PHI in isolated, moderate-severe TBI patientsin associated with a nearly 5-fold increase

in mortality.Bukur M, Kurtovic S, Berry C, et al. J Surg Res 170, e117-e121. 2011


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Paralytics are not recommended in the urbanEMS setting for airway management

Airway clearance/establishment to prevent

hypoxia If using RSI/DAI in the field, monitor:

BP

SpO2 EtCO2

Consider the following: BVM with nasal or oral airway

Rescue airway (e.g. Combitube

, King Airway

)
http://allemt.com/wp-content/uploads/2013/09/KINg.jpg


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Transient respiratory arrest after TBI

Inability to protect airway with GCS 8

Early intubation for adequate ventilation andoxygenation*

Obtain a brief neurologic exam prior tosedation/intubation


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EMS Assessment Continuous monitoring for hypoxia

Goal: SpO2> 90%

SpO2> 90%: Mortality 14%; Morbidity 3%

SpO260 89% Mortality 27%; Morbidity 27%

SpO2< 60% Mortality 50%; Morbidity 50%
http://en.wikipedia.org/wiki/File:Saturometre_2.jpg


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Hypoxemia is damaging to injured brain, provide100% oxygen

Ventilate at a normal rate EtCO2goal: 35-40 mmHg

Vt: 6-7 cc/kg and rate 10 breaths/min

Hyperventilation is a rescue maneuver and isutilized for brief periods with continuous EtCO2monitoring EtCO2< 35 should be avoided for extended periods of

time


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Hypotension is almost never due to braininjury or hypovolemia from brainhemorrhage.

Exsanguination can occur from scalplaceration

Hypotension (SBP < 90 for 5 min) doubles brain injury mortality (60% vs. 27%)

additional hypoxia increase mortality to 75%


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Goal:

Maintain SBP > 90 mm Hg; MAP > 65

Treatment Correct hypotension with isotonic fluids

0.9% Normal Saline

Lactated Ringers (LR)

Consider hypertonic saline (3%) if GCS < 8

250 mL 500 mL bolus


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EYES OPEN4 Spontaneously3 To Verbal Command2 To Pain

1 No Response

BEST VERBAL RESPONSE5 Oriented and Converses4 Disoriented and Converses

3 Inappropr iate Words2 Incomprehensible Sounds1 No response

BEST MOTOR RESPONSE

6 Obeys5 Localizes to Pain4 Flexion Withdrawal3 Decorticate posturing2 Decerebrate posturing

1 No Response

Glasgow Coma Score


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Mild GCS 14-15 80%

Moderate GCS 9-13 10%

Severe GCS 3-8 10% Causes 65% of mortality in MVC

In hospital mortality about 30%

Full neurologic recovery rare


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Damage to the brain caused by the

initial insult

Only prevention will decrease this Seatbelts

helmets

EMS goal to prevent secondaryinjury


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Assess for cerebral herniation Dilated, non-reactive pupils Asymmetric pupils Posturing motor exam Progressive neurologic deterioration

Pupil exam First rule out orbital trauma Check after resuscitated/stable Unilateral or bilateral dilated pupils

Asymmetry

Fixed and non-responsive


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Pain Control

No scientific evidence improves outcomes

Opiates/Ketamine may INCREASE ICP Mannitol

Osmotic diuretic

1 gram/kg for signs of herniation Hypoglycemia

Assess for using finger stick

Correct hypoglycemia


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EMS system with goal the rightpatienttothe rightplacein the rightamount of time

Strategies Limit pre-hospital time

Transport vehicle quickest means to closest center

Transport to facility which has: CT scan capabilities

ICP monitoring

Neurosurgical Care


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Usually bleeding from

Middle Meningeal

Artery Lucid interval

Lens shaped from

pushing the dura off

the skull Surgery to remove

mass


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Usually bleeding from

bridging veins

Concave shapefollows skull

Surgery to remove

mass effect

Associatedunderlying brain

contusion


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Which would you rather have?


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Bleeding insubarachnoid space

Trauma or rupturedcerebral aneurysm

Layers in the sulci allaround the brain

May inducevasospasm, ischemia,or seizures


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Blood in the tissue ofthe brain

Diffuse axonal injury Shear injury to axons. Terrible prognosis

May require surgery

to remove large clotor large amount ofdamaged brain


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The Monroe-Kellie Doctrine


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Increased volume in a

closed space results

in either increased

pressure in the space

or loss of some

content of the space.

Describes the natural

history of intracranial

injury (early 1700s)

Brain

Blood

CerebrospinalFluid


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Small to moderatemass effect iscompensated bydecreased CSF anddecreased bloodvolume due tovenous compression

Normal ICP

Brain

Blood

CerebrospinalFluid

Mass


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Maximum loss ofCSF and venous

blood

Mass results inbrain compression

Elevated ICP

Brain

Blood

Cerebrospinal Fluid

Mass


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Mass causes such

severe compression

that arterial flow is

lost

Very High ICPs

Herniation of brain

tissue

Brain death

Brain

Cerebrospinal Fluid

Mass


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Herniation

Uncal herniation (2)

Compression of CN III Dilated pupil

Decrease level of consciousness

Cushing reflex

Cerebellar herniation (4) Pushed down foramen

Rapid pulmonary failure


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Factors which make brain injury

worse or enlarge area of injury: Hyperglycemia

Hyponatremia

Hypotension

Hypoxia

Hyperthermia

Hypercarbia


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Trauma

GCS 3-8 and abnormalhead CT

GCS 3-8 and normalhead CT but two of thefollowing: age > 40,hypotension, posturing

Clinical signs of

increased intracranial

pressure


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Flow to the brain is the most important

Perfusion pressure is used instead of flow

CPP = MAP ICP

Normal ICP < 10 cm H2o Acceptable ICP < 20 cm H2o Normal CPP > 70 cm H2o


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Prevent Secondary Injury

Decrease skull contents

Decrease brain metabolic demand

Improve CPP


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The mass is abnormal--

Surgical removal is

optimal

Subdural and Epidural

hematomas

Surgery may not be an

option due to location or

multiple small lesions

Brain

Blood

CerebrospinalFluid

Mass


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Ventriculostomy !!!

Brain

Blood

Cerebrospinal Fluid

Mass


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Only venous blood can bedrained without causingischemia

Raise the head of bed

Keep Head straight

Loosen collar

No Jugular lines

Hyperventilation

Brain

Blood

CerebrospinalFluid

Mass


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Osmolar therapy--

increased blood

osmolarity decreasesbrain fluid

Mannitol -- treatment

only, not prophylactic

Hypertonic Saline

Brain

Blood

CerebrospinalFluid

Mass


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Analgesia

Sedation

Paralysis

Cooling

Pentobarbital Coma


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ICP should be controlled first, if abnormal

If not controlled, increased MAP will provideperfusion to the brain despite high ICP{Cushings Reflex}

Usually use Neosynephrine


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Has been used as initial management in past.

Works by causing hypocarbic vasoconstriction

of cerebral blood vessels

DECREASES CEREBRAL BLOOD FLOW

Works only for a short time Should be used as last ditch therapy Try to keep pCO2 normal.


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Treat Surgical lesions

Prevent secondary injury

Enhance venous drainage

Provide sedation and analgesia

Drain CSF if ventriculostomy is available

Maximize Osmolar therapy


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Airway protection?

Hyperventilation??

Head elevation with C-spine control

***Maintenance of blood pressure*** Permissive hypotension not applicable

Osmotic diuresis vs. 3% Saline

Seizure prophylaxis???


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Steroid Administration

Furosemide Administration

Hemoglobin Level

Hypothermia

Anticonvulsant Therapy

Never

Theoretical

> 10 g/dL

Difficult

Recommended


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10-15% of severe head injuries will developintractable elevated ICP

Mortality 84-100%

Treatment Paralysis

Pressors to enhance MAP

Intermittent hyperventilation

Pentobarbital coma

Drastic measures . . . . . .


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Remember what the dormouse said:

Feed your Head. Feed your Head.

--JeffersonAirplane

sagraves traumatic brain injury

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