Alyssa Morris, R4 August 12, 2010 Thanks to Dr Adam Oster

 Prehospital intubation of a head injury  Anti-seizure prophylaxis  Intubation of a head injury  Premedication  Induction agent  Management of herniation  Mannitol  Hypertonic saline  Cooling in TBI  CT head rules

 27M restrained driver in a single vehicle MVA at highway speed.  GCS 13, no obvious head trauma, other vitals stable, combative  26F restrained passenger in the rollover GCS 8, obvious lacerations and bleeding from scalp, BP 102/60, P= 110, 02 sats 94% RA

 Objective: determine if ALS care in field for trauma patients improves morbidity and mortality  Design: Before-after clinical trial  Population: n= 2867, trauma pts >16y.o, severity score>12  Results: (ALS v. BLS)  Overall Survival 81.1% v. 81.8% (p=0.65)  Survival in GCS<9 50.9% v. 60.0% (p=0.02)

 The patients are now in the ED.  27M GCS 14 one hour after exam, no obvious amnesia, slightly agitated, vitals stable and nothing else on exam.  26F GCS 8 obvious depressed skull fracture.

1. Do you want to ask radiology for a CT head for these patients? 2. What were the outcomes the rule was predicting? 3. What are the High Risk criteria? 4. What are the Medium Risk criteria?

 Objective: develop a highly sensitive clinical decision rule for use of CT in pts w minor head injury  Inclusion Criteria:  blunt trauma to the head w witnessed LOC  definite amnesia  witnessed deterioration  initial ED GCS >=13  injury w/i past 24h

 Exclusion Criteria  <16y.o  Minimal head injury  No clear hx of trauma  Penetrating skull injury  Focal neuro deficit  Unstable vital signs  Had a seizure before ED assessment  Bleeding disorder or anticoagulated  pregnant

 High Risk (for neurological intervention)  GCS < 15 at 2 hrs after injury  Suspected open or depressed skull #  Any sign of basal skull fracture  Vomiting >= 2 episodes  Age >= 65  Medium Risk (for brain injury on CT)  Amnesia before impact >= 30 min  Dangerous mechanism ▪ Pedestrian ▪ Ejected ▪ Fall from elevation >=3ft or 5 stairs

 The nurse asks if you want to give these patients dilantin to prevent a seizure given they have head injuries. The female reportedly has already had a seizure but the male has not. Q: Will you give dilantin to the 27M? Q: Will you give dilating to the 26F?

 6 randomized controlled trials included  Results  For every 100 pts treated with AEDs, 10 would be kept seizure free in 1 st week  No reduction in mortality  No reduction in neurological disability  No reduction in late seizure onset  Conclusion  Does reduce early PTS but no outcome benefit  No evidence to support routine use at any time after injury

 Practice Recommendations  Prophylactic treatment with phenytoin, beginning with an IV loading dose, ASAP after injury should be used routinely to prevent early PTS  Prophylactic treatment should not be used beyond first 7 days after injury

 Recommendations  LEVEL I ▪ Insufficient data  LEVEL II ▪ AEDs are indicated to decrease the incidence of early PTS (w/i 7d of injury). However, early PTS is not associated with worse outcomes. ▪ Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS

 Recommendations  Standards ▪ Insufficient data  Guidelines ▪ Prophylactic use of AEDs to prevent late PTS is not recommended  Options ▪ Prophylactic use of AEDs to prevent early PTS may be considered as a treatment

 27M is becoming more combative and you are preparing to intubate him. Q: Will you premedicate? Q: What will you use for induction?

 1.5mg/kg 3 minutes before RSI  No article answering our exact question  Found 6 papers  Benefit shown in:  Brain neoplasms undergoing resection  ETT suctioning (already intubated and Mx)  No benefit or harm shown in:  Prolonged decreased MAP (CPP= MAP-ICP)  Has to be given minutes before RSI

 Objective: use swine model with ICP monitors in to monitor changes with different versions of RSI  Groups: 1)Thiopental 2) Thiopental and Sux 3) Lido, Thiopental, Sux 4) pancuronium, lido, thiopental, sux

 Advocated for use in premedication  Rosen’s  AIME  US airway course  3mcg/kg 3 minutes before  No evidence from our setting or at time of ETI

 Objective: determine the effect of fentanyl on ICP in head injured sedated patients with monitors in place  Design: randomized  Results:  Significant increase in ICP transiently  Significant decrease in MAP  Significant decrease in CPP

 Objective: determine the effect of fentanyl on ICP and CBF in sedated patients with severe head injury  Design: Randomized  Results:  Significantly increased ICP  Significantly decreased MAP  No change in CBF

 The case against Ketamine 1. Gardner et al. Intracranial CSF pressure in man during ketamine. Anesth Analg. 1972;51: Shapiro et al. Ketamine anesthesia in patients with intracranial pathology. Br J Anesth. 1972;44: Takeshita et al. The effects of ketamine on cerebral circulation and metabolism in man. Anesthesiology. 1972;36:69-75.

 Objective: determine effect of IV Ketamine on ICP/CPP/MAP  Population: 8 ventilated patients with ICP monitors in place  Intervention:1.5, 3 and 5mg/kg IV  Results:  Significant reduction in ICP

 Design: prospective double-blind RCT  Population: 25 pts with severe head injury  Intervention: continuous infusion of ketamine-midazolam v. sufentanil- midazolam  Results  No significant difference in daily ICP  No significant change in daily CPP

 Design: prospective RCT  Population: 35 patients with moderate or severe head injury  Intervention: ketamine-midazolam v. fentanyl-midazolam infusions  Results  Slightly higher ICP in ketamine group (2mmHg)  Slightly higher CPP in ketamine group (8mmHg)

 Increases ICP  Old studies in patients with abnormal CSF flow  Increases CPP ▪ Not sure of the effect this has on regional blood flow to penumbra and outcome assoc w this  Neuroprotective  NMDA R antagonist  decreases glutamate (neurotoxic)  ?neuroprotective  Some animal models, nothing strong in humans

 Your patients are now both intubated.  What are you initial vent settings and what goal(s) do you give the RT?  If the patient shows evidence of herniation how does this change you approach to ventilation?

 Not Herniating  Mode: AC  Vt= 8cc/kg  PEEP= 5  PCO2=  RR=  Herniating  Hyperventilate until clinical recovery or definitive Mx

 LEVEL I  Insufficient evidence  LEVEL II  Prophylactic hyperventilation (PaCO2 of 25) isnot recommended  LEVEL III  Hyperventilation is recommended as a temporizing measure for the reduction in elevated ICP

 STANDARDS  Insufficient data  GUIDELINES  Insufficient data  OPTIONS  Mild hyperventilation (PCO2<35) should be avoided  Mild hyperventilation may be considered for long periods of refractory high ICP  Aggressive hyperventilation (PCO2<30) may be considered for brief periods in cases of cerebral herniation or acute neuro deterioration

 The female patient now has a blown pupil.  How do you want to manage this?

1. HYPEROSMOLAR THERAPY 1. Mannitol 2. Hypertonic Saline 3. Barbiturates 2. HYPERVENTILATION 3. SURGERY

 Objective: Compare high dose barbiturates to mannitol for ICP control  Design: RCT  Results:  ICP significantly lowered in mannitol group  CPP significantly improved  Mortality improved

 Level I Evidence  Insufficient data to support level I evidence  Level II Evidence  Mannitol is effective for control of ICP  Dose of 0.25g/kg-1g/kg  Avoid SBP<90  Level III Evidence  Restrict to use in patients with signs of herniation OR w an ICP monitor in

 Design: Prospective  Objective: effect 3% Saline continuous infusion on refractory elevated ICP in severe HI pediatric patients  Results  Statistically significant decrease in ICP  Statistically significant decrease in # of ICP spikes  Statistically significant increase in CPP

 Design: prospective RCT pilot  Population: 9 patients with ICP>20  Intervention: 200cc bolus of 20% Mannitol v 100cc bolus of 7.5% Saline over 5 minutes  Results:  Significant reduction in ICP with HS compared to mannitol  Both reduced ICP (13mmHg v 7.5mmHg)

 Current evidence is not strong enough to make recommendations on the use, strength and method of administration of hypertonic saline

 Standards  Not enough evidence  Guidelines ▪ Not enough evidence  Options  HS is effective for control of ICP after severe head injury ▪ 3% Saline 0.1mL/kg to 1.0mL/kg continuous  Mannitol is effective for control of ICP after severe head injury ▪ g/kg bolus

 Your patients are now intubated, stable and ICU is rounding so want you to manage them for a few hours.  The nurse asks if you want to cool the patients.  Are you going to cool this patient?

 Design: large multicenter RCT  Intervention: hypothermia (33C) initiated w/i 6 hrs for 48hrs v. normothermia  Population: n= 362, age with coma after CHI  Results: (hypo v. normo)  Poor functional outcome: 57% vs 57%  Mortality: 28% vs 27%  Fewer hypothermic patients had high ICP

 Design: multicenter, international, RCT  Intervention: hypothermia (32.5C for 24hr w/i 8hrs of injury) v. normothermia (37C)  Population: n= 225, Age 1-17 with TBI and GCS<8, CT w brain injury and need for mechanical ventilation  Results: (hypo v. normo)  Unfavorable outcome 31% v 22% P= 0.14  Deaths 23 v 14 P=0.06

 LEVEL I EVIDENCE  Insufficient data  LEVEL II EVIDENCE  Insufficient data  LEVEL III EVIDENCE  Pooled data indicate hypothermia is not significantly associated with decreased mortality  It is associated with significantly higher outcome scores  Need to maintain for >48hrs

 STANDARDS  Insufficient data  GUIDELINES  Insufficient data  OPTIONS  Extrapolated from adult data, hyperthermia should be avoided  Despite lack of evidence, hypothermia may be considered in cases of refractory intracranial htn

 Maintain normothermia  What if they are febrile?

 Intubate in field?  CT head rules pocket guide  AED prophylaxis?  Premedication with lido/fentanyl?  Induction with ketamine? In whom?  Use of mannitol for herniation?  Use of hypertonic saline for herniation?  Vent strategies?  Cooling?

 5M who fell off a chair and hit the temporal side of his head on the side of a table. No loss of consciousness. Next day vomits 6 times and complains of headache  7F falls from the Jungle Gym (7ft) and hits her head. No amnesia, no LOC, normal exam  18m.o. M fell from change table onto hardwood floor. Cried immediately. Has had a good feed but is slightly irritable when you examine him