Head Injury Practical Aspects of Management and Transfer. Susanne Young

CONTENT Head Injuries Background Head Injuries Background INITIAL MANAGEMENT INITIAL MANAGEMENT Current Guidelines- ATLS Current Guidelines- ATLS Prevention of secondary Brain Injury (1-4) Prevention of secondary Brain Injury (1-4) Use of adjunct therapies Use of adjunct therapies TRANSFER TRANSFER Which Sedative? Which Sedative? AAGBI AAGBI

BACKGROUND Head injury accounts for approximately 300 per hospital admissions per year; of these, 9 per die. Head injury accounts for approximately 300 per hospital admissions per year; of these, 9 per die. RTA's account for about 25% of cases and about 60% of deaths; many die before reaching hospital. RTA's account for about 25% of cases and about 60% of deaths; many die before reaching hospital. The aim of management is to minimise damage arising from secondary complications. The aim of management is to minimise damage arising from secondary complications.

PROGNOSIS Traumatic Brain Injury- prognosis at 48HRS Traumatic Brain Injury- prognosis at 48HRS GCS <8- severe moderate mild

INITIAL MANAGEMENT A- secure a clear airway and control cervical spine A- secure a clear airway and control cervical spine B- treat hypoventilation, severe chest injury B- treat hypoventilation, severe chest injury C- control haemorhage and treat shock C- control haemorhage and treat shock D- assess disability D- assess disability E-exposure, prevent hypothermia * E-exposure, prevent hypothermia *

Principles of management Prevention of secondary cerebral injury: Prevention of secondary cerebral injury: 1 Hypoxia 1 Hypoxia 2 ICP 2 ICP 3 CPP and CBF 3 CPP and CBF 4 Cerebral metabolism 4 Cerebral metabolism

1 HYPOXIA PO2 <10kPa for any reason PO2 <10kPa for any reason If hard collar Consider: If hard collar Consider: 2 person Manual in-line immobilisation 2 person Manual in-line immobilisation 3 rd person cricoid 3 rd person cricoid Use of McCoy blade Use of McCoy blade ?Blind Nasotracheal intubation –exc if Basal skull #- if skilled ?Blind Nasotracheal intubation –exc if Basal skull #- if skilled

2 Control of ICP Signs of raised ICP (>20mmHg) Signs of raised ICP (>20mmHg) Papilloedema, BP, HR,fixed pupils, flaccid, irreg resps (brainstem involvement) ?Hypoventilate- if in doubt DON’T ?Hypoventilate- if in doubt DON’T Moderate hypocapnia CO OK Consider if GCS drops suddenly Very low CO2 –vasoconstriction ischaemia

Control of ICP (contd). Fluid balance- overload can exacerbate cerebral and pulmonary oedema Fluid balance- overload can exacerbate cerebral and pulmonary oedema Sedate initially- Sedate initially- Propofol first line Add Midaz if ineffective ? Thio- may cause haemodynamic disturbance ? Mannitol g/kg (100ml 20%). ? Mannitol g/kg (100ml 20%). Buys time only, nephrotoxic- watch uo.

3 Control of CPP and CBF CPP= MAP- ICP mmHg CPP= MAP- ICP mmHg Min CPP 60/70 for adequate perfusion Min CPP 60/70 for adequate perfusion Cushing reflex designed to restore CPP in presence of ICP therefore Cushing reflex designed to restore CPP in presence of ICP therefore Don’t treat Hypertension! Don’t treat Hypertension! Mainstay of treatment is to keep SBP>90 Mainstay of treatment is to keep SBP>90 Steroids ineffective (palliative care only) Steroids ineffective (palliative care only)

Control of Cerebral Metabolism Prevent fits. Prophylaxis in first week. Prevent fits. Prophylaxis in first week. Phenytoin 15mg/kg loading Phenytoin 15mg/kg loading Avoid Benzo’s if poss. Avoid Benzo’s if poss. ? Active cooling ? Active cooling Moderate hypothermia (32-33 for 24hrs) of benefit if GCS at presentation5-7

TRANSFER INTUBATE AND VENTILATE- but don’t hyperventilate. INTUBATE AND VENTILATE- but don’t hyperventilate. SEDATE WITH PROPOFOL SEDATE WITH PROPOFOL A LINE, CATHETER, ECG etc A LINE, CATHETER, ECG etc Prophylactically- join AAGBI! Prophylactically- join AAGBI! become a member of the Group of Anaesthetists in Training (GAT). become a member of the Group of Anaesthetists in Training (GAT). Free insurance to cover you during any inter- hospital ambulance transfers ! Free insurance to cover you during any inter- hospital ambulance transfers ! Free insurance Free insurance