Presentation is loading. Please wait.

Presentation is loading. Please wait.

Severe Traumatic Brain Injury Francesco Della Corte, MD Associate Professor University A. Avogadro, School of Medicine Novara, Italy.

Similar presentations


Presentation on theme: "Severe Traumatic Brain Injury Francesco Della Corte, MD Associate Professor University A. Avogadro, School of Medicine Novara, Italy."— Presentation transcript:

1 Severe Traumatic Brain Injury Francesco Della Corte, MD Associate Professor University A. Avogadro, School of Medicine Novara, Italy

2 On the site of accident 3.30 pm Male 34 yrs old GCS 6 (V1; E1; M4) Pupil size unequal (left > right -not reactive) Gasping Abdominal distension Fracture of the left leg RSI, ETI, sedation and volemic infusion MVA High speed Deformity on the left side Francesco Della Corte, MD

3 At the ED at 4.30At the ED at 4.30 GCS 6 (V1; E1; M4)GCS 6 (V1; E1; M4) Pupil size unequal (left > right -not reactive) Left eyelid contusion and bulb rotated left and downwardLeft eyelid contusion and bulb rotated left and downward Flexion at the right arm to painFlexion at the right arm to pain AP 73/43 mmHg; HR 135 bpmAP 73/43 mmHg; HR 135 bpm SpO2 100%; Hb 4.5 g/dlSpO2 100%; Hb 4.5 g/dl Abdominal US: positiveAbdominal US: positive Chest Xray (multiple left chest rib fractures)Chest Xray (multiple left chest rib fractures) Transported immediately in the OR for splenectomyTransported immediately in the OR for splenectomy Francesco Della Corte, MD

4 E.R. O.R. ICU Rescue/transport Diagnosis

5 Key Questions Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemiathe role and prevention of cerebral ischemia The ABCsThe ABCs Is preH ETI an absolute priority in the managementIs preH ETI an absolute priority in the management of the STBI? When to hyperventilate or not to hyperventilate?When to hyperventilate or not to hyperventilate? What is the gold target for BP?What is the gold target for BP? What about sedation in severe HI?What about sedation in severe HI? How much to rely on the first CT for further evolution and prognosis?How much to rely on the first CT for further evolution and prognosis?

6 Out of the OR 5.45 pm Sedation and analgesiaSedation and analgesia (propofol 2.5 mg/Kg/h & remifentanyl 0.05 mcg/kg/min)(propofol 2.5 mg/Kg/h & remifentanyl 0.05 mcg/kg/min) GCS 6 (V1; E1; M4) + persisting pupils unequalGCS 6 (V1; E1; M4) + persisting pupils unequal BP 125/76 mmHg; HR 95 bpmBP 125/76 mmHg; HR 95 bpm SpO2 100%; Hb 9.5 g/dlSpO2 100%; Hb 9.5 g/dl CT scanCT scan The Case Cont’d

7 CT scan Francesco Della Corte, MD

8 Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemiathe role and prevention of cerebral ischemia Prognosis of HI is strictly related to:Prognosis of HI is strictly related to: degreedegree duration of cerebral ischemiaduration of cerebral ischemia More than 90% of authopsies in HI showed ischemic lesions of different severity Graham D.I., Adams J.H. Ischemic brain damage in fatal head injuries. Lancet 1: , 1971 Francesco Della Corte, MD

9 Postraumatic cerebral ischemia Intracranial hypertension Arterial hypotension Brain swelling or Cerebral edema Focal compression due to intracerebral or extrassial hematomas Vasospasm Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemia Francesco Della Corte, MD

10 Martin NA, Patwardhan RV, et al: Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm.J Neurosurg 87: 9-19, 1997 Day CBF ml/100g/min CBF ml/100g/min I IIIII Phase Time course and CBF in head injury 45 Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemia

11 Pbp O 2 Van den Brink, Neurosurgery 46; , 2000 Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemia mM in CSF Glutamate Days after TBI Yamamoto: Acta Neurochir S75: 31-34, 1999

12 Elevation of microdialysate lactate concentration after head injury Goodman JC, Crit care med 27; , 1999 Fig. 3 up 1day 2 day 3 day 4 day 5 day Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemia Francesco Della Corte, MD

13 Priorities in the treatment of severe head injuries: The ABCsThe ABCs A irway patency B reathing C irculation D isability E xposure Antioxidants Barbiturates Calcium antagonists Dexamethasone E vitamine Francesco Della Corte, MD

14 Airways patency Priorities in the treatment of severe head injuries: the ABCs Francesco Della Corte, MD

15 Guidelines Hypoxemia (apnea, cyanosis or arterial hemoglobin O 2 saturation < 90%) must be avoid, if possible, or corrected immediately… Hypoxemia should be corrected by administering supplemental oxygen Options The AW should be secured in patients with GCS < 9, with inability to maintain an adequate airway or hypoxemia not corrected by supplemental O 2. Endotracheal intubation, if available, is the most effective procedure to maintain the airway Airway patency ABCs BTF – AANS Francesco Della Corte, MD

16 Early endotracheal intubation Indications: Airway obstruction in any case Maintainance of an adequate oxygenation and ventilation Prevention of hyper and hypocapnia Protection of airways obstruction Prevention of neurological deterioration in hostile environments (transport, radiological procedures) ABCs Airway patency Airway patency Francesco Della Corte, MD

17 Orotracheal intubation should be preferred Blind nasotracheal intubation is to be avoided: In any case a fracture of the basis (and maxillar) is suspected It needs the patient breaths spontaneously High percentage of failures It could give nasal bleeding (obstacle to orotracheal intubation) A cervical spine lesion must ever be suspected in a a comatose patient. Treat him/her as having a spine injury ABCs Airway patency Airway patency Francesco Della Corte, MD

18 Murray JA J Trauma Dec;49(6): Prehospital intubation in patients with severe head injury. For patients with severe head injury, prehospital intubation did not demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results. Bochicchio GV J Trauma 2003 Feb; 54(2): Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. ABCs Is preH ETI an absolute priority in the management of the HI? Is preH ETI an absolute priority in the management of the HI? Francesco Della Corte, MD

19 Brescia 2°, Lecco, Milano Niguarda, Milano Policlinico, Milano San Raffaele, Monza, Pavia 2°, Roma, Sondalo, Varese Ancona Bologna Bellaria, Cesena Genova Galliera Roma Gemelli Torino CTO Treviso, Vicenza Trieste Patients G. Citerio, N. Stocchetti, M. Cormio, L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp CENTERS 3 months

20 Pre-H intubation G. Citerio, N. Stocchetti, M. Cormio, L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp Is preH ETI an absolute priority in the management of the HI? ABCs

21 Breathing Priorities in the treatment of severe head injuries: the ABCs Francesco Della Corte, MD

22 Priorities in the treatment of severe head injuries: ABCs BUT should they be BUT should they be hyperventilated or not to hyperventilated? hyperventilated or not to hyperventilated? All intubated patients must be ventilated to obtain : adequate oxygenation (paO 2 > 90 mmHg, SaO 2 > 95%) adequate oxygenation (paO 2 > 90 mmHg, SaO 2 > 95%) prevention of hyper- or hypocapnia, with PaCO 2 at 35 mmHg prevention of hyper- or hypocapnia, with PaCO 2 at 35 mmHg Recommendations for the treatment of adults with severe head trauma (Part I) – Min. Anest. 5,1999

23 186 pts (Bouma 1991) (Robertson 1992; Jaggi 1990; Marion 1991, Martin 1997) < > 48 CBF ml/100 g/min Hours post injury Priorities in the treatment of severe head injuries: When to hyperventilate or not to hyperventilate? Priorities in the treatment of severe head injuries: When to hyperventilate or not to hyperventilate? Francesco Della Corte, MD

24 Brain Trauma Foundation, et al:J Neurotrauma, 17: , 2000 Standards: In the absence of increased ICP chronic prolonged hyperventilation (25 mmHg or less) should be avoided Guidelines: prophylactic hyperventilation (<35 mmHg) during the first 24 hours should be avoided Options: Hyperventilation may be necessary for brief periods when there is neurologic deterioration, or for longer if there is intracranial hypertension refractory to sedation, paralysis, CSF drainage and osmotic diuretics. Priorities in the treatment of severe head injuries: Priorities in the treatment of severe head injuries:ABCs

25 C irculation Priorities in the treatment of severe head injuries: the ABCs Francesco Della Corte, MD

26 699 patients Mortality (SHI at time of arrival at ER) = 36.6 % Mortality % 27 % Neither 75 % 60 % 33 % HypoxiaHypotension Both Chesnut RM et al. J trauma 1993; 34: Francesco Della Corte, MD

27 Secondary insults first 24 hrs % 11% 14% 18% None Hypoxia Hypotension Both Mutually exclusive Hypotension = SBP  90 mmHg or cyanosis or no peripheral pulse Hypoxia = SaO 2  90 or apnea or cyanosis G. Citerio, N. Stocchetti, M. Cormio, L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp Francesco Della Corte, MD

28 Secondary insults - GOS 6 months Both 51%18% Hypotension 54%26% Hypoxia 25%44% None 19%52% (  ) Hypotension = SBP  95 mmHg or cyanosis or No peripheral pulse Hypoxia = SaO 2  90 or apnea or cyanosis GOS G. Citerio, N. Stocchetti, M. Cormio, L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp Francesco Della Corte, MD

29 Hypotension and Head Injury Manley G,Arch Surg p= Francesco Della Corte, MD

30 Priorities in the treatment of severe head injuries: ABCs Hypoxemia (<90% arterial hemoglobin oxygen saturation or apnea, cyanosis or a paO 2 < 60 mmHg) Hypotension (<90 mmHg systolic blood pressure) are significant parameters associated with a poor outcome in patients with STBI in the prehospital setting Guidelines for Prehospital Management of TBI. BTF, 1999 C irculation Francesco Della Corte, MD

31 Priorities in the treatment of severe head injuries: ABCs CPP should be maintained at greater than 60 mmHg in adults CPPs of 50 mmHg or lower have been shown to be associated with critical reductions and with increased mortality following severe TBI No study has found that the incidence of intracranial hypetension, morbidity or mortality is increased by the active maintainance of CPP above 60 mmHg …. Artificial attempts to maintain CPP above 70 mmHg may be associated with an increase incidence of ARDS Guidelines for the management of STBI: CPP - BTF – AANS March 14,2003 W hat is the optimal target for BP? C irculation Francesco Della Corte, MD

32 keep systolic BP > 110 mmHg in adults to ensure adequate cerebral perfusion pressure Priorities in the treatment of severe head injuries: ABCs C irculation Recommendations for the treatment of adults with severe head trauma (Part I) – Min. Anest. 5,1999 What is the optimal target for BP? Francesco Della Corte, MD

33 Priorities in the treatment of severe head injuries: ABCs Priorities in the treatment of severe head injuries: ABCs The value of 90 mmHg SBP to delineate the threshold for hypotension has arisen arbitrarirly and is more statistical than a physiologic parameter….. It may be valuable to maintain MAP considerably above those represented by SBP of 90 mmHg… Guidelines for Prehospital Management of TBI. BTF, 1999 Is MAP a better endpoint than systolic BP? Francesco Della Corte, MD

34 Key Questions Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries: the role of cerebral ischemiathe role of cerebral ischemia ABCsABCs Is preH ETI an absolute priority in the management of the HI?Is preH ETI an absolute priority in the management of the HI? To hyperventilate or not to hyperventilate?To hyperventilate or not to hyperventilate? What is the gold target of BP?What is the gold target of BP? What about sedation?What about sedation? How much to relay on the first CT for further developments?How much to relay on the first CT for further developments? Francesco Della Corte, MD

35 Priorities in the treatment of severe head injuries: What about sedation? Midazolam mg/kg or Propofol 1-2 mg/kg iv (attention to hypotension) Propofol 1-2 mg/kg iv (attention to hypotension) if hypotensive or bleeding thiopental 1 mg/kg or midazolam mg/kg; Succinylcholine 1 mg/kg iv. or vecuronium 0.1 mg/kg iv. Sedation/analgesia should be continued, using short-acting drugs so that neurological assessments can be made at regular intervals in the ED. Muscle relaxing drugs should be avoided if possible. Recommended sedation protocol for ETI in TBI – Italian guidelines, 1999 Francesco Della Corte, MD

36 Priorities in the treatment of severe head injuries: What about sedation? MIDAZOLAM Deo S The use of midazolam in trauma resuscitation. Eur J Emerg Med Sep;1(3): …… Midazolam was found to be a safe and viable alternative to muscle relaxants, allowing endotracheal intubation and ventilation Davis DP Prehosp Emerg Care Apr-Jun;5(2): …….The use of midazolam with prehospital RSI is associated with a dose-related incidence of hypotension. Francesco Della Corte, MD

37 Priorities in the treatment of severe head injuries: What about sedation? ETOMIDATE Dearden NM Comparison of etomidate and althesin in the reduction of increased intracranial pressure after head injury. Br J Anaesth Apr;57(4): : Dearden NM Comparison of etomidate and althesin in the reduction of increased intracranial pressure after head injury. Br J Anaesth Apr;57(4): : Schockenhoff B Use of etomidate within the scope of neurosurgery Zentralbl Neurochir. 1985;46(2): German. 3: Hinds CJ. Etomidate and adrenocortical function. Intensive Care Med. 1984;10(5): : Cohn BF Results of a feasibility trial to achieve total immobilization of patients in a neurosurgical intensive care unit with etomidate. Anaesthesia Jul;38 Suppl: : Prior JG The use of etomidate in the management of severe head injury. Intensive Care Med. 1983;9(6): : Schulte am Esch J, The influence of etomidate and thiopentone on the intracranial pressure elevated by nitrous oxide. Anaesthesist Oct;29(10): German.

38 Priorities in the treatment of severe head injuries: What about sedation? KETAMINE Bourgoin A. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med Mar;31(3):711-7 …… ketamine in combination with midazolam is comparable with a combination of midazolam-sufentanil in maintaining intracranial pressure and cerebral perfusion pressure of severe head injury patients placed under controlled mechanical ventilation. Francesco Della Corte, MD

39 Priorities in the treatment of severe head injuries: What about sedation? LIDOCAINE EV lidocaine prevents the increase in ICP that occur during ETI Many RSI protocols include L several minutes before laringoscopy No literature could be found to support the use of L as a single agent prior intubation Francesco Della Corte, MD

40 Key Questions Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries: the role of cerebral ischemiathe role of cerebral ischemia ABCsABCs Is preH ETI an absolute priority in the managementIs preH ETI an absolute priority in the management of the HI? of the HI? To hyperventilate or not to hyperventilate?To hyperventilate or not to hyperventilate? What is the gold target for BP?What is the gold target for BP? What about sedation?What about sedation? How much to rely on the first CT for further developments and prognosis ?How much to rely on the first CT for further developments and prognosis ? Francesco Della Corte, MD

41 CT scan 12 hrs later Francesco Della Corte, MD

42 Timing of CT scan First CT as soon as possible Second CT before 12 hrs if first within 3 hrs after trauma within 24 hrs Third CT before 72 hrs after the trauma A CT scan must be obtained in case of any clinical deterioration or increase in ICP Recommendations for the treatment of adults with severe head trauma (Part I) – Min. Anest. 5,1999 How much to rely on the first CT for further developments and prognosis?

43 Initial scan vs Worst scan DI I - DI II - DI III - DI IV - Mass lesion DI I - DI II - DI III - DI IV - Mass lesion DI I 89% 4% 2% 0% 4% DI II 81% 4% 1% 14% DI III 85% 1% 13% DI IV 80% 20% Mass lesion 100% Servadei et al Neurosurgery, Vol 46, n.1, January 2000 How much to rely on the first CT for further developments and prognosis ? Francesco Della Corte, MD

44 Which patients are at high risk for ICP elevation?

45 Clinical case: outcome The patient remained in the ICU 9 days. He had intermittent increases of ICP during the first 4 days responsive to medical treatment He was operated at the left leg on day 4 He was extubated on day 8 He was transferred to Neurosurgical ward and now he came back to his work with only a minor paresis of the left arm Francesco Della Corte, MD

46 Conclusions Brain ischemia is the most relevant pattern in STBI especially in the first 24 hrs. Head injured patients require aggressive approach in the acute phase for the prevention of secondary insults. Hypoxia and hypotension are the most frequent, important (and preventable) complications Referral to hospitals with neurosurgical facilities should be the gold standard where surveillance, diagnosis and prompt surgical intervention could be provided in case of detection of mass lesion Francesco Della Corte, MD

47 No single “magic bullet” has been developed The cornerstone of management of head-injured patients remains the prevention of initial injury and the minimization or reversal of secondary insults Teasdale GM Neurosurgery 1998 Conclusions Francesco Della Corte, MD

48


Download ppt "Severe Traumatic Brain Injury Francesco Della Corte, MD Associate Professor University A. Avogadro, School of Medicine Novara, Italy."

Similar presentations


Ads by Google