Management of Acute Neurotrauma
Grey MatterNext Level Neuro Resus26 June 2015William A Knight
IV, MD, FACEPUniversity of Cincinnati
Traumatic Brain Injury 10 Things you Need to Know
[email protected]@waknight4
Why TBI Really Matters Now
TBI has become the signature injury of the Afghanistan and Iraq
conflicts.
2
24 y/o male presents via EMS
High speed MVA unrestrained110/80 118 10 100% on 100% NRBGCS 6
(E2 V1 M3)Right pupil 5mm Left pupil 3mm
RSI (etomidate, succinylcholine, no lidocaine) Vent: SIMV 40% 14
520 cc 15/5
Head, C-spine, Abdomen-Pelvis CT
3
OR
Decompressive hemicrani5
ICU
External Ventricular Drain (EVD) placedLiCox PbO2/brain temp
monitor placedContinuous EEG monitoring
3% hypertonic saline per protocolLeviteracetam
prophylaxisPropofol and fentanyl gtt
6
Epidemiology: TBI in the US
50,000 Deaths100,000Hospitalizations1,111,000Emergency
Department Visits?? Receiving Other Medical Care or No Care*
Average annual numbers, 1995-20012004 CDC Report: TBI in the United
States: ED Visits, Hospitalizations, and Deaths1.5 2.0 millionTBIs
occur each year.*
7From 1995 to 2001, an average of 1.4 million TBIs occurred in
the United States each year. Of them, most (79.6%) were ED visits,
followed by hospitalizations (16.8%) and deaths (3.6%).
This does not accurately take into account all the minor TBIs /
concussions.
The problem with TBI
Primary injury happens before we can interveneAll post-injury
intervention is aimed at preventing secondary injury
Secondary injury isremarkably complicated
8
The problem with TBI
Primary injury happens before we can interveneAll post-injury
intervention is aimed at preventing secondary injury
Secondary injury isremarkably complicated
9
TBI
The real problem of TBI heterogeneous disease, homogenous
treatment. 10
Secondary Injury
TBI
Demyelination
MitochondrialUncoupling
Excitotoxiccascade
Receptor activation
ReducedGABA
InflammatoryCytokines
Apoptosis
CerebralEdema
CytotoxicEdema
VasogenicEdema
Pro Apoptotic cascade
Free radicals & lipid peroxidation
What we haveWhat we need
Historical mortality in severe TBI exceeded 50%
Despite years of research and new technology, adjusted mortality
rate remains near 25%
12
Secondary InjuriesSystemicCentral Nervous
SystemHypoxiaHypotensionAnemiaHyperthermia Hyper/hypocarbia*Fluid
imbalanceSepsisHematomaBrain swellingBrain
herniationSeizuresHydrocephalusIschemiaInfection
The sources of current evidence
2007
Level 1 Evidence in TBI
Steroids (NNH 37)
Top 10
10 Mechanical Support
Mechanical support c-collar, HOB > 30, midline
19
Head of bed 30degLoosen c-collarHead midlineBlankets -
temperature20
9 Anticoagulation Reversal
Anticoagulation Reversal in TBIDrugReversal
MethodEvidenceCostAspirin (ASA) PlateletsDemsopressin (DDAVP)rFVIIa
(40mcg/kg)weak$1000 12 units
$1 / mcg Plavix (Clopidogrel)PlateletsDemsopressin (DDAVP)rFVIIa
(40mcg/kg) terrible$1000 12 units
$1 / mcg Warfarin (Coumadin) Vit KFFP (250 cc /
bag)PCCCryoprecipitaterFVIIa (40mcg/kg) good$10 / 10mg$60 /
bag$5000 / dose$1200 / 20 bags$1 / mcg TSOACsPCC
(depends)AntidotesWeak???$5000 /
dose???HeparinProtaminesolidNSAIDSPlateletsDDAVPgarbage$1000 12
units
Population is aging
High rate of warfarin and anti-platelet therapy
Warfarin usage in elderly TBIGCS < 8 mortality rate of
88%
22
8 - AnalgoSedation
Ketamine is safe? PropofolFentanylDexmetatomidine
Pain first23
7 Avoid extremes
EucapniaNormoxiaEuthermiaEunatremiaEuvolemia
24
Fall back on the ABCs and pay attention.
Avoid hypoxia (any SaO2 < 90 %)Increases neuronal death and
motor deficitsCorrelates with poor outcomes Occurs at least once in
39%
Avoid hypotension (any SBP < 90 mmHg)Mortality rates double;
morbidity increasesLate hypotension seen in 32%; 66% become V/D
(vs. 17%)Do not treat BP (maintain cerebral perfusion)
Hypoxia had OR of 2.66 for deathCombination hypoxia +
hypotension OR of 14 for death
25
PaCO2 =25 mm Hg
PaCO2 = 40 mm Hg
Temporizing onlyActive signs / symptoms of herniationBlown pupil
Extensor posturing Cushings triadAvoid hyperventilation if possible
in first 24 hr
CBF = 3-4% per each 1% in PaCO2PCO2 effect transient due to HCO3
bufferingSignificant rebound effect
26
Maintain normalMaintain physiologic homeostasisNothing supra or
sub-therapeuticPrevent secondary
injuryNormoxiaNormotensionEuthermiaEucapniaEuvolemia
Outcomes by presenting oxygenation
Avoid hypoxia (any SaO2 < 90 %)Increases neuronal death and
motor deficitsCorrelates with poor outcomes Occurs at least once in
39%
Avoid hypotension (any SBP < 90 mmHg)Mortality rates double;
morbidity increasesLate hypotension seen in 32%; 66% become V/D
(vs. 17%)Do not treat BP (maintain cerebral perfusion)
Hypoxia had OR of 2.66 for deathCombination hypoxia +
hypotension OR of 14 for death
27
But.what about?
osmolality is comparable to mannitolHigher coefficient of
reflection than mannitolElevated osmolality is maintained longerICP
reductions are similar or greater than mannitol 5 20 mmHgCPP
maintained due to improved hemodynamic stability
28
Mechanism of Action
Vialet, et al. Crit Care Med 2003;31:1683-7; Qureshi, et al.
Neurosurgery 1999; 44:1055-63
29
6 Early
Early
Seizure prophylaxis 7 daysEarly nutritionEarly DVT
prophylaxisGlucose monitoringEarly mobilityEarly trach/peg?31
5 Mechanical Ventilation
Inappropriate ventilator settings can be lethal
Lung protective ventilationResult of ARDSnet dataVt
6-8cc/kgIdeal body weightPplat < 30 cm H2O
Limit excessive FiO2Oxygen toxicity
Use minimal settingsVigilant with hypercapnia
33
Lung Protective Ventilation
NEJM 2000
34
Tidal Volume in TBI
4 - Monitoring
Multimodality monitoring in severe TBIWhat to monitorGoals of
monitoringHow to integrate multiple data pointsHow to train
clinicians on all the above
Monitors dont affect outcome. Care affects outcome. Dont get
lost in the numbers pay attention to the whole patient.
36
Generalized spike/wave status
EtCo2 monitoring37
3 Surgical Management
Decompressive Craniectomy
DECRA TrialNEJM March 2011Worse functional outcome155/3500
enrolledBifrontal craniMore pts with fixed/dilated pupilsUnusual
ICP trigger
ProblemsToo often, too late, too smallCraniectomy / duraplasty /
+/-lobectomy
ThoughtsYounger patients may better candidatesMay not be useful
when irreversible brainstem damage has occurredCurrent military
practice early and aggressive
40
2 Early Aggressive Care
41
Severe TBI Outcomes by Admission GCS
Narayan et al, J Nsurg 1981
Importance of accurate GCS in the ED or in the field. 42
Outcome: GCS 8Marshall et al, J Nsurg 1991
GCS 8 post resuscitation43
There is no Number 1
Were missing somethingDECRAProTECT
Disease definition
Can what we see contributing to poor or good outcome be as wrong
as these trials suggest or do we need to define the disease and
patients better?
Multicenter RCTs can be successfully performed
Do we change our approach?
Adeoye O & Shutter L. Neurotrauma & Critical Care of the
Brain. Jallo J, ed. Thieme; 2009. CPP?
46Best evidence is to target CPP ~ 60
Under-recognized disease?
Cerebral IschemiaPresent in 90% of severe TBI patients who
die
What is the mechanism of ischemia?ICP vs CPP
mismatchVasospasmHypotensionFailed autoregulation
47
Conclusions
ConclusionsTarget normal physiologic goals
Research We know how to studyDo we know what to study?
Early aggressive care is the future24 hours of resuscitation
prior to prognosis
Its not an exceptional case. We just dont know how many
exceptions to the rule there are.
So.I dont believe in the rule anymore. - Joseph Giacino,
PhDhttp://nymag.com/scienceofus/2015/06/dylan-rizzo-coma.html
Volume-Pressure Curve
Intubate for GCS < 8Sedation and pain controlHyperosmolar
therapyLicox monitorSeizure monitoringSeizure
prophylaxisCoagulopathy reversalEarly nutritionEarly DVT
prophylaxisDVT screening
Advancements - NPKPatients exam should be described as GCS, as
this is translatable throughout the TBI communityHypotension should
be avoided or immediately corrected with isotonic fluidsAvoid
prophylactic hyperventilationAvoid hypoxiaICP monitoring in
patients with severe TBI who are salvageableShort acting pain
medication / sedation should be provided to patients who are
intubated with severe tbiRoutine seizure prophylaxis should not
occur past 7 days post injurySteroids should not be
administeredHead of bed elevated to help decrease ICPEarly DVT
prophylaxis?
AdeoyeTriage, acute management and follow-up of mild TBI more an
ED question butMultimodality monitoring in severe TBIWhat to
monitorGoals of monitoringHow to integrate multiple data pointsHow
to train clinicians on all the above
BonomoMechanical support (HOB, c-collar loose, head
midline)Avoid hypoxiaAvoid hypotensionEarly ct scanningDo not give
up on gcs 3 non-penetrating in first 24 hoursOptimize preload and
avoid volume overloadPaO2 80-120 until we have better tissue o2
data to drive decision makingRemember the neuro-cardiac axis, echo
early, echo oftenIntrathoracic pressure influences ICP, keep an eye
on lung complianceAPRV is ok in TBI if compliance is ok.
Hypothermia treats ICP, use it when neededEEG is mandatory
zammitNormoxia, normocarbiaNormotension, optimize CPPCorrection
of coagulopathyHOB 30, loose c-collar, head straightEuvolemia,
normonatremiaNormothermiaAnalgosedationEarly nutrition, glucose
controlEarly decompression / CSF diversion If tSAH nimodipine, VSP
monitoringDelayed prognostication
Avoid hypotensionManagement of ICP/maintain CPPSeizure
prophylaxisAvoid secondary injury from
seizureNeuromonitoringEvacuate mass lesionsTreat infectionsEarly
and appropriate nutritionEarly rehab, stimulant, early trach,
PEG
Advancements - CZWider implementation of BTF guidelinesEMS
implementation of prehospital guidelines
