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John Peterson, DO KU School of Medicine - Wichita

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1 John Peterson, DO KU School of Medicine - Wichita
Breathing for the Head John Peterson, DO KU School of Medicine - Wichita

2 Disclosures I’ve known Alan and Jeff for a while……

3 Objectives Neurological injuries Physiological effects
Airway management Ventilator management

4

5 Neurological injuries
Disturbances in consciousness Encephalopathy Traumatic brain injury Acute Myelopathy Ischemic stroke Intracerebral hemorrhage Subarachnoid hemorrhage Brain tumors Status epilepticus Venous thrombosis Cerebral Sinus DVT/PE Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, pp xi - xiii

6 Disturbances in Consciousness
Drowsy Stupor Minimally conscious state Vegetative state Restored sleep/wake cycle Locked – in syndrome Coma Brain death Concerns for airway management and ventilatory effort Drowsy – mild depression in consciousness (aroused to waking by voice) Stupor – unresponsiveness requiring greater and repetitive physical stimulus for arousal Minimally conscious state - some awareness of self and/or environment Locked – in syndrome – Complete or near complete paralysis of extremities, usually from damage to midbrain pontine structures. Communication may be possible by eye movement Coma - profound disturbance in consciousness involving both the reticular activating system and cerebral hemispheres, disturbed sleep/wake cycle no meaningful interaction with the environment Brain Death – irreversible loss of all brain function

7 Encephalopathy Vascular Trauma Neoplasm Seizure Organ Failure
Metabolic Endocrine Pharmacologic CNS infection Systemic infection Inflammatory and immune – mediated encephalitis Vascular - Ischemic stroke - Intracerebral hemorrhage - SAH - Cerebral venous thrombosis - Vasculitis - Posterior reversible encephalopathy syndrome (PRES) Trauma - Focal brain lacerations and contusions - Extra – axial hematomas - Diffuse axonal injury Neoplasm - Primary and secondary tumors Seizure - Generalized (convulsive, nonconvulsive) - Complex partial seizures Organ Failure - Cardiac arrest (anoxic – ischemic encephalopathy) - Respiratory (encephalopathies associated with hypoxia, hypercapnia) - Hepatic encephalopathy - Uremic encephalopathy Metabolic - Severe electrolyte imbalance -Hypoglycemia; hyperglycemic states - Cofactor deficiency (Wernicke encephalopathy) Endocrine - Hypothalamic and pituitary failure - Thyroid (myxedema coma, thyrotoxicosis) - Adrenal (Addison disease) Pharmacologic/toxic - Prescription medications - opioids, benzodiazepines, barbiturates, tricyclics, neuroleptics, aspirin, SSRIs, acetaminophen, anticonvulsants - Drugs of abuse - opioids, alcohol, methanol, ethylene glycol, amphetamines, cocaine, hallucinogens - Environmental exposures - carbon monoxide, heavy metals CNS infection - Meningitis - Encephalitis Systemic infection - Septic encephalopathy Inflammatory and immune – mediated encephalitis - Postinfectious encephalitis - Post – vaccine encephalitis - Paraneoplastic encephalitis - Lupus encephalitis - Neurosarcoidosis - Acute disseminated encephalomyelitis (ADEM) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 289

8 Traumatic Brain Injury
Primary injury Secondary injury May be more injurious Hypoxia and hypoperfusion most likely are the most critical factors in secondary injury Primary injury - What lead to hospitalization (Prevention is the only treatment) Secondary injury - Ischemic injury - Hypoxia (local or global) - Excitotoxicity - Free radical damage - Ionic dysregulation - Inflammatory mediators - Intracranial hypertension - Hyperthermia Focal injury - Localized deficits - Delayed hematomas may develop Diffuse injury - DAI (diffuse axonal injury) - Axonal shearing in cerebral white matter - causes focal deficits and encephalopathy Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 308

9 Acute Myelopathy Traumatic Degenerative spine Neoplastic Inflammatory
Systemic disease Bacterial and viral infections Vascular Toxic/Metabolic Traumatic - Fracture/dislocation/ligament injury - Disc herniation - Epidural hematoma - Cord contusion Degenerative spine - Spondylosis Neoplastic - Primary - Neoplastic Inflammatory - Transverse myelopathies - Paraneoplastic - Parainfectious Systemic disease - Sarcoidosis - SLE - Beheet disease - Sjogren syndrome - Polyarteritis nodosa Bacterial and viral infections - Epidural abscess - Bacterial myelitis - Tuberculosis - Poliovirus - Varicella zoster - Herpes simplex - Cytomegalovirus - HIV - Human T-cell lymphotropic virus – 1 - Syphilis - Lyme disease - Schistosomiasis - Toxoplasma gondii Vascular - Spinal cord infarction - Arteriovenous malformation - Hemorrhage Toxic/Metabolic - Vitamin B12 deficiency - Copper deficiency - Radiation - Medication related - Hepatic myelopathy

10 Stroke Defined Focal neurological deficit that has an arterial distribution that correlates with specific region of the brain

11 Normal Brain

12 Ischemic stroke Focal neurological deficit corresponding to arterial territory Transient ischemic attack (TIA) Symptoms resolve in less than 24 hrs Typically less than 1 hr Reversible Ischemic Neurologic Deficit (RIND) Symptoms lasting 24 – 72 hrs 80% of all strokes 3rd highest cause of mortality after heart dz and cancer for patients > 40 y/o One stroke every 45 sec. One death from stroke every 3 min Leading cause of disability Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 341

13 Ischemic Stroke

14 Ischemic stroke Embolic Thrombotic Cardiac Artery to artery embolus
Paradoxical embolus Thrombotic Intracranial atherosclerosis Lipohyalinosis Arterial dissection Arteritis Fibromuscular dysplasia Vasospasm Hypercoaguable states Cardiac - Atrial fibrillation Artery-to-artery - embolism from thrombi generated on the surface a stenotic lesion to the distal branches Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 342

15 Ischemic Stroke Modifiable Non-modifiable Diabetes mellitus
Hypertension Smoking Hypercholesterolemia Coronary artery disease Non-modifiable Age Male Family history Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 342

16 Intracerebral Hemorrhage

17 Intracerebral Hemorrhage
10 – 15% of all strokes 30 day mortality: 35 – 52% Only 20% are independent functional at months Etiology Primary Secondary to hypertension Secondary Aneurysmal, AVM, Tumor, Amyloid angiopathy, Coagulopathies, Trauma Highest mortality of the stroke types More common in males, > 55 y/o, Blacks and Japanese

18 Intraventricular Hemorrhage

19 Subarachnoid Hemorrhage
Trauma Most common cause Spontaneous 80% Aneurysmal 10 – 15% Perimesencephalic nonaneurysmal hemorrhage 5% Nonaneurysmal 2 – 5% of all strokes

20 Subarachnoid Hemorrhage

21 Vasospasm Occurs between days 4 -12
Lasts up to 21 days Monitoring with transcranial doppler (TCD) Treatment for symptomatic vasospasm Triple H Hypertension Hypervolemia Hemodilution Angiography with balloon dilation or intra-arterial calcium – channel blocker infusion

22 Epidural Hematoma Subdural Hematoma

23 Post-Cardiac Arrest Brain Injury
Therapeutic hypothermia Indicated for out-of-hospital ventricular fibrillation arrest Possible benefit with asystole and PEA 55% of the hypothermia group had a favorable outcome vs 39% in the normothermia group At 6 months 41% of the hypothermia group died vs 55% of the normothermia group Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 393

24 Venous Thrombosis Cerebral Sinus DVT/PE Rare cause of stroke
Thrombophilia is most common cause Systemic anticoagulation required DVT/PE 79% of pulmonary embolism originates from a lower extremity deep vein thrombosis Neurological conditions predisposing to VTE Spinal cord injury Traumatic brain injury Ischemic stroke Intracerebral hemorrhage Malignant glioma Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p ,

25 Venous Thrombosis Deep Vein Thrombosis Risk Factors
Venous valvular insufficiency Right-sided heart failure Postoperative period Prolonged bedrest Extremity trauma Malignancy and cancer therapy Pregnancy and postpartum period Hormone therapy Spinal cord injury History of venous thromboembolism Hypercoagulable state Hypercoagulable state - Antithrombin III deficiency - Protein C deficiency - Protein S deficiency is not clinically significant - Factor V Leiden mutation - Increasing age/obesity/smoking - ICU Factors - Paralysis, prolonged ventilation, severe sepsis, central venous catheter, consumptive coagulopathy, HIT Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p

26 Malignant Hyperthermia
Autosomal dominant condition Triggers Halogenated inhalational anesthetics Succinylcholine Extreme stress, vigorous exercise and heat exposure Risk Factors Myopathies Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 437

27 Malignant Hyperthermia
Signs and symptoms Unexpected rise in end-tidal CO2 > 55 or PaCO2 >60 Increased minute ventilation Unexplained tachycardia, ventricular tachycardia or fibrillation, labile blood pressure, congestive heart failure Metabolic acidosis with elevated serum lactate Altered mental status (when anesthetic is stopped) Generalized muscle rigidity, masseter rigidity (despite neuromuscular blockade), rhabdomyolysis Acute renal failure Hyperkalemia Hyperthermia (Temperature can rise 1 – 2 C˚ q 5 min up to 44˚C) This is a late finding DIC Especially with temp > 41˚C Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 438

28 Malignant Hyperthermia
Management Stop offending agent Admit to ICU Increase minute ventilation to normalize PaCO2 Body cooling NG icy lavage, ice packs, fans, surface or invasive cooling systems Target temp of 38.5 Dantrolene Continue for 3 days IV or PO dosing Monitor for excessive muscle weakness or hepatotoxicity Monitor for recrudescence Hyperkalemia treatment - Hyperventilation - Albuterol (10mg via neb) - Kayxalate - Glucose (1 amp DW 50%) + insulin (10 units regular) - Calcium gluconate - Bicarbonate Rhabdomyolysis - IV fluids at 200ml/hr target urine output 2ml/kg/h, consider diuretics - Monitor for signs of DIC, follow electrolytes, creatine phosphokinase, renal function Recrudescence associated factors - Muscular body type - MH grading score > 35 - Temperature increase - Period between induction to adverse reaction > 150 min Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 438

29 Neuroleptic Malignant Syndrome
Risks Prior physical exhaustion and dehydration Previous episode of NMS Exposure to antipsychotic drugs Signs and symptoms Develop within 24hrs – 1 month after exposure to antipsychotic drugs Regression within 1 wk – 1 month after discontinuation of drug 10% Mortality NMS dx 2000 annually 0.01 – 0.02% incidence of pts treated with antipsychotic medication Higher potency and doses can increase risk Signs and Symptoms: - Elevated temperature and severe extrapyramidal muscle rigidity after exposure to antipsychotic drug - Plus two assoc signs or symptoms - Mental status change - Tremors - Dysautonomia: tachycardia or bradycardia, labile blood pressure, tachypnea or hypoxia diaphoresis, incontinence or sialorrhea - OR - Laboratory abnormalities: rhabomyolysis, metabolic acidosis, leukocytosis, generalized EEG slowing Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p

30 Brain Tumors Second most common cause of death from intracranial disease 33% overall 5 year survival 33% of all tumors are gliomas 67% are high grade Metastatic tumors are the most common brain neoplasm Lung (18 – 64%) Breast (2 – 21%) Melanoma (4 – 16%) Colorectal tumors (2 – 12%) Renal cell carcinoma (1 – 8%) Lymphoma (< 10%) Unknown origin (1 – 18%) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p

31 Brain Tumors

32 Brain Tumor

33 Brain Tumors Headache Seizure Progressive focal neurological deficits
Visual defects Altered mental status Intracerebral hemorrhage Intracranial pressure elevation

34 Hydrocephalus Caused by impaired cerebrospinal fluid flow, reabsorption or excessive production Cerebrospinal fluid Forms at 0.3mL/min 20mL/hr 500mL/day Total volume ~150mL 75mL in cranial vault Normal pressure ~10mmHg Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p

35 Hydrocephalus

36 Hydrocephalus

37 Neuromuscular Disorders
Acute generalized weakness CNS Bilateral hemispheric Brainstem Spinal cord Motor neuron West Nile infection Poliomyelitis Enterovirus infection Neuromuscular junction Myasthenia gravis Lambert-Eaton myasthenic syndrome Organophosphate poisoning Botulism Tick Paralysis Hypermagnesemia Snake/insect/marine toxins Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

38 Neuromuscular Disorders
Acute generalized weakness causes cont. Neuropathies Guillain – Barré syndromes Critical illness polyneuropathy Chronic idiopathic demyelinating polyneuropathy Toxic neuropathies Vasculitic neuropathy Porphyric neuropathy Diptheria Lymphoma Carcinomatous meningitis Acute uremic polyneuropathy Eosinophilia-myalgia syndrome Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

39 Neuromuscular Disorders
Acute generalized weakness causes cont. Myopathies Critical illness myopathy Dermatomyositis Polymyositis Periodic paralysis/hypokalemic myopathy Myotonic dystrophy Acid maltase deficiency Muscular dystrophies Mitochondrial myopathies Corticosteroid-induced myopathy Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

40 Neuromuscular Disorders
Causes of acute respiratory muscle weakness CNS Diseases of high cervical cord or medulla Motor neuron disease Neuromuscular junction Myasthenia gravis Lambert-Eaton myasthenic syndrome Neuropathies Idiopathic bilateral phrenic nerve paresis Guillain-Barré syndrome (rare) Neuralgic amyotrophy Large artery vasculitis Multifocal motor neuropathy Myopathies Acid maltase deficiency Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 478

41 Neuromuscular Disorders
Causes of acute predominantly bulbar weakness CNS Brainstem diseases Bilateral white matter diseases Syrinx Motor neuron Amyotrophic lateral sclerosis Kennedy disease Neuromuscular junction Myasthenic gravis Lambert-Eaton myasthenic syndrome Botulism Neuropathies Guillan-Barré syndrome (rare) Carcinomatous meningitis Skull base tumor or metastases Miller-Fisher disease Sarcoidosis Basilar meningitis Myopathies Dermatomyositis Polymyositis Oculopharyngeal muscular dystrophy Myotonic dystrophy Distal myopathy with vocal cord paralysis Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 479

42 Neuromuscular Disorders
Acute failure of the autonomic nervous system CNS Diseases affecting the hypothalamus, brainstem, medulla, high cervical cord R insular stroke Neuromuscular junction Lambert-Eaton myasthenic syndrome Botulism Neuropathies Diabetic autonomic neuropathy Amyloid neuropathy Guillain-Barré with predominant dysautonomia Paraneoplastic dysautonomia Connective tissue disorders Sjogrens Systemic lupus erythematosus Infectious Chagas HIV Leprosy Diptheria Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 479

43 Neuromuscular Disorders
Indications for ICU admission Respiratory weakness FVC < 40ml/kg NIF < - 40 cmH2O > 30% decline in FVC or NIF in 24 hrs Signs of fatigue or dyspnea Significant neck flexor weakness or poor cough CXR Infiltrates, atelectasis or pleural effusion Dysphagia/inability to protect airway Increased aspiration risk Bulbar dysfunction/bilateral facial weakness Failed swallow evaluation Autonomic instability Dysrhythmia Blood pressure lability Profound sensitivity to sedatives Planned interventions Plasma exchange Frequent vital checks or intensive nursing care Rapid onset of symptoms (< 7 days) (R-R interval prolongation may predict a fatal dysrhythmia) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 480

44 Neuromuscular Disorders
Intubation indications Consider early intubation May reduce pulmonary complications FVC < 20 mL/kg NIF < - 30 cmH2O PaO2 < 70 (decrease by > 50% in 24 hrs) on room air Hypoventilation (PaCO2 > 45) Dysphagia (PaCO2 > 45 or significantly increasing) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 480

45 Neuromuscular disorders
Extubation criteria Pressure support of 5 with PEEP 5 for > 2hrs (prolonged SBT) Some evidence for PS of 0 with PEEP of 5 or T-piece predicts more successful extubation Successful secretion management Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 481

46 Status Epilepticus A seizure that persists a sufficient length of time or is repeated frequently enough to produce a fixed and enduring epileptic condition Historically, is defined by a seizure lasting 30 min and should be considered for seizures lasting 5 – 10 min Nonconvulsant status epilepticus should be considered with coma patients with unclear etiology May occur in as many as 8 -34% of critically ill patients Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 489

47 Status Epilepticus Etiologies Neurovascular Tumor CNS Infection
Inflammatory disease Traumatic brain injury Primary epilepsy Hypoxia/ischemia Drug/substance toxicity or withdrawl Fever Metabolic abnormalities Neurovascular: Stroke, AV malformations, Hemorrhage Tumor: Primary, metastatic CNS Infection: Abscess, Meningitis, Encephalitis Inflammatory disease: Vasculitis, Acute disseminated encephalomyelitis Traumatic brain injury: Contusion, Hemorrhage Primary epilepsy Hypoxia/ischemia Drug/substance toxicity: Antibiotics, antidepressants, antipsychotics, bronchodilators, local anesthetics, immunosuppressives, cocaine, amphetamines, phencyclidine Drug/substance withdrawl: Barbiturates, benzodiazepines, opioids, alcohol Fever: Febrile sz Metabolic abnormalities: Hyponatremia, hypophosphatemia, hypoglycemia, renal/hepatic dysfunction, surgical injury (craniotomy) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 491

48

49 Status Epilepticus Medical treatment Airway and ventilator management
May require inducing a coma Neuromuscular blockade Will not stop the seizure, only the motor manifestation Airway and ventilator management May not be required for nonstatus seizure Will be required for induced coma Benzodiazepines initial treatment Effective 65% of the time Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 499

50 Spinal Cord Injury Trauma is the most common cause
~ 50% are motor vehicle related 24% related to falls 9% sports injury 11% assault > 50% involve the cervical spine Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 325

51 Spinal Cord Injury Diaphragm
Innervated by cervical spine segments C3 – C5 Injury at or above this level results in immediate ventilatory failure Below the diaphragmatic level Diaphragm is preserved Intercostals are compromised Decreased vital capacity, maximal inspiratory support and decreased expiratory force Spasticity develops leading to improved forced vital capacity and maximal expiratory force Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 333

52 Spinal Cord Injury Post injury
Rapid shallow breathing transiently compensates for the injury Atelectasis develops 1/3 will require intubation Consider intubation when VC < 1L Intubate if decreased LOC, impaired cough or unable to manage secretions Avoid succinylcholine if weak or paralyzed for ≥ 2 days 2 – 7 days) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 333

53 Neurogenic Pulmonary Edema
Occurs in with severe acute neurological injury Incidence 40% of head injury patients 90% intracerebral hemorrhage Caused by alveolar injury from catecholamine stor Treatment: Intubation, PEEP, Elevated FiO2, possibly diuretics

54

55 Neurological evaluation

56 Neurological Evaluation
Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 313

57 Physiological Effects of Neurological Injury
Cerebral Blood Flow Controlled by the arteriole constriction and relaxation Hypoventilation Hypercarbia Hypoxia

58 Autoregulation metrohealthanesthesia.com

59 Cerebral Perfusion Pressure (CPP)
CPP = Mean arterial pressure (MAP) – Intracranial pressure (ICP)/Central venous pressure (CVP)

60 Monro-Kellie Doctrine

61 Monro-Kellie Doctrine

62 Hyperventilation PaCO2 Normal CBF
1 mmHg change in PaCO2 produces ml/100 Gm/min change in CBF (in same direction) Transient effect (wanes in 6-8 hours) Normal CBF PaCO2 = 40 mmHg

63 Management ABC Airway Intubation GCS < 8 or rapid worsening GCS
Uncontrolled seizures Intubation Controlled induction Avoiding hypo or hypertension Consider lidocaine to blunt elevation in ICP Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p 357

64 Management ABC Breathing Circulation ICP monitoring
Higher mortality rate in neurological patients than nonneurologic patients despite a lower incidence of extracerebral organ dysfunction Avoiding secondary injury Lung Protective Ventilation Circulation Target CPP 60 – 80 mmHg ICP monitoring Necessary to accurately measure CPP Cohort study Pelosi, et. al. Crit Care Med 2011 Vol. 39, No. 6

65 Ventilator management
Mode PEEP Oxygenation O2 saturation > 90% PaO2 > 60 mmHg ARDS Lung protective ventilation Neurogenic pulmonary edema Level III evidence Oxygenation should be monitored and hypoxia (PaO2 60 mm Hg or O2 saturation 90%) avoided. Bullock, R, M.D., Ph.D., Deputy Editor, Povlishock, J., Ph.D. Editor-in-ChiefGuidelines for the Management of Severe Traumatic Brain Injury of Severe Traumatic Brain Injury 3rd ed, 2007 Brain Trauma Foundation, Inc.

66 PEEP PEEP Increases Decreases Intrathoracic pressure
Peak inspiratory pressure Mean airway pressure Decreases Venous return Mean arterial pressure Cardiac output

67 PEEP PEEP 5 – 15 mmHg Generally tolerated in patients at risk for elevated ICP Elevated ICP should be closely monitored with changes in PEEP

68 Venous Drainage

69 Extubation Neurosurgical patient GCS = 4 were successfully extubated
Intact cough and gag Strategy Is the neurological injury reversible? What is the duration of injury? If long term neurological injury anticipated Early tracheostomy

70 Extubation Criteria Signs of appropriate muscle strength
Vital capacity > 15 – 20 mL/kg Mean inspiratory pressure < -20 to -50 cmH2O FiO2 < 40% and PEEP ≥ 5 cmH2O No fever, infection or other medical complications

71 Pulmonary toilet Endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients Increased ICP Increased CPP No change in oxygenation The increase in jugular venous oxygen tension associated with increases in middle cerebral artery velocity and mean arterial pressure suggests that cerebral oxygen delivery was maintained during ETS. Cerebral changes associated with ETS using the described protocol are consistent with the preservation of cerebral oxygenation. Kerr, et al, Critical Care Medicine, Volume 27(12), December 1999, pp

72 Monitors ICP Monitors Bolt External Ventricular Drain (EVD)
Pressure monitor External Ventricular Drain (EVD) Drainage of CSF Parenchymal ICP monitor (Codman) Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p

73 Monitors Tissue oxygenation Tissue metabolic activity
Jugular venous saturation Brain tissue oxygenation (Licox) Near – infrared spectroscopy Tissue metabolic activity Microdialysis catheter SjO2 monitoring - estimate of oxygen delivery to the brain with goal mean values of 56 – 74% - the higher is desirable - Oxygen extraction is determined by arterio-venous difference Low brain tissue oxygen tension (PBRO2) may correlate with poor outcome or death cerebral concentrations of oxygenated hemoglobin ([HbO2]) and deoxygenated hemoglobin ([HbR]) were assessed during brain activation using near infrared spectroscopy (NIRS). Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011, p

74

75 Summary Recognition of neurological injury ABCs
Intubation and Ventilation Extubation

76 References Bhardway, Anish, et. al., ed, Handbook of Neurocritical Care, 2nd ed. Springer, 2011.


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