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Traumatic Brain Injury (TBI): Moderate/Severe ALGORITHM 1: Post-Resuscitation

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Traumatic Brain Injury (TBI): Moderate/Severe ALGORITHM 1: Post-Resuscitation CLINICAL PATHWAY Traumatic Brain Injury (TBI): Moderate/Severe ALGORITHM 1: Post-Resuscitation Glasgow Coma Scale (GCS) 9-12 Glasgow Coma Scale (GCS) Post resuscitation less than or equal to 8 Inclusion Criteria: (Consider for children under 2 years old with Post-resuscitation Patient with traumatic concern for acute abusive head trauma) brain injury and Glasgow Coma Scale (GCS) less than or equal to 12 Exclusion Criteria: Emergency Department Management Patients found down without clear Trauma and Neurosurgery Consult traumatic brain injury (TBI) Head Computed Tomography (CT) scan- if not already obtained (STAT upload) or a quick MRI as a viable (radiation-free) option (Can be used in conjunction with Post 2 IVs with Normal Saline (NS) as maintenance Cardiac Arrest Pathway if Modified Rapid sequence intubation (RSI) if not already performed considered beneficial) For patients with signs of elevated intracranial pressure (ICP) Monitor GCS. GCS empirically treat decrease to less than Yes • 3% (0.5 mEq/mL Na+) Hypertonic saline (HTS) bolus 5mL/kg/dose via or equal to 8? peripheral IV or central line • For patients with ongoing seizures use the status epilepticus clinical pathway (below). • For patients with severe TBI who have not received a dose of levetiracetam at another institution, give levetiracetam 20mg/kg IV No (max 2 grams) • If transporting to Operating Room: Consider mild hyperventilation to PCO2 of 32-35 mmHg • Consider comfort sedation and standard neuroprotective measures. • Complete frequent Surgery neurologic exams. No Indicated? Yes Surgery as indicated • Standard Neuroprotective measures** • Standard neuroprotective Improving or No monitoring *** stable? • Anschutz: Neurocritical Care (NCC) Consult OR Colorado Springs: Neurology Rehab Considerations for Consult Yes Severe TBI Patients • Consult Physical Medicine & If external ventricular drain Continue clinical monitoring and **Standard Neuroprotective Rehabilitation (PM&R) for (EVD)/intracranial pressure (ICP) consult Physical Medicine & Measures: patients that have stabilized Rehabilitation (PM&R) monitor placed per neurosurgery, or have been hospitalized follow • Head of bed at 30⁰, midline greater than 5 days Intracranial pressure (ICP) • Non-restrictive cervical-collar ***Neuroprotective Monitoring: management algorithm • Consult PT/OT within 48 • Sodium greater than 140 • End Tidal CO2 (ETCO2), core (Next page) hours of admission for early temperature mmol/L passive range of motion, • If needed, central access and • Normothermia 36.8 ⁰C bracing & splinting, and out of bed when appropriate arterial line • Oxygen Saturation 93%-97% • Consult speech therapy • Intracranial pressure (ICP) • PCO 35-40 mmHg 2 when patient stabilized or monitor or external ventricular • Normoglycemia 80-180 mg/dL have been hospitalized for drain (EVD) placed if needed per greater than 5 days neurosurgery in emergency • Levetiracetam 10mg/kg/dose department, Operating room, or BID x 7 days (Max dose • Anschutz: Consult rehab PICU 1,000mg BID) neuropsychology when • Continuous EEG (cEEG) when • Appropriate sedation PM&R is consulted stabilized *Post Cardiac Arrest Clinical Pathway *Status Epilepticus Clinical Pathway Page 1 of 15 CLINICAL PATHWAY Algorithm 2. Moderate/Severe Traumatic Brain Injury (TBI) Intercranial Pressure (ICP) Management Moderate/Severe Traumatic Brain Injury (TBI) Intercranial Pressure Neuroprotective Monitoring: • End Tidal CO2 (ETCO2), core (ICP) Management Algorithm: temperature • If needed, central access and arterial line Intracranial pressure (ICP) Inclusion Criteria: • Intracranial pressure (ICP) monitor monitor placed at the discretion Patients with Moderate/severe or external ventricular drain (EVD) of neurosurgery TBI with an ICP monitor in placed if needed per neurosurgery place in emergency department, operating Sedate for comfort. room, or PICU Responsive to touch or Exclusion Criteria: • Continuous EEG (cEEG) when name. See sedation Patient without an ICP stabilized section for guidance. monitor in place Age MAP ICP CPP (mmHg) (mmHg) (mmHg) Neuroprotective 0-2 50-70 <15 35-55 monitoring including ICP 2-5 60-80 <20 40-60 6-8 65-85 <20 45-65 Elevated intracranial pressure 9 + 70-95 <20 50-75 No Elevated ICP? (ICP) Parameters Mean Arterial Pressure (MAP), Cerebral Perfusion pressure (CPP) ICP For patients that are calm, less than 20 unstimulated and outside of cares: Standard Neuroprotective Measures: Yes • Actively treat for an ICP of • Head of bed at 30⁰, midline greater than 20-25 mmHg for Ensure appropriate • Non-restrictive cervical-collar External more than 10 minutes cerebral spinal fluid Yes ventricular drain • sodium greater than 140 mmol/L (CSF) drainage. See CSF Drainage box. (EVD) in place? For a patient that is in pain, agitated • Normothermia 36.8 ⁰C or receiving cares: • O2 Sat 93%-97% No • Ensure appropriate sedation/ • PCO2 35-40 mmHg ICP Hyperosmolar Therapy analgesia • Normoglycemia 80-180 mg/dL greater than 20 Bolus hypertonic saline (HTS) if sodium • Consider treating ICP greater less than 165 mmol/L then 30 mmHg for longer than 10 • Levetiracetam 10mg/kg BID x 7 days If fluid overloaded or not responsive to minutes after appropriate (Max dose 1,000mg BID) HTS, bolus mannitol 0.5-1g/kg/dose if sedation or the end of cares osmolarity (Osm) less than 340 MOSM/ Kg. Can Repeat after 15 minutes if ICP is When treating, treat to a goal ICP Fluid Goals and Vasoactives elevated of less than 20 mmHg • Maintain cerebral perfusion pressure (CPP) and euvolemia • If euvolemic, use ionotropic/ vasopressor support Yes Elevated ICP? No Cerebral Spinal Fluid (CSF) Drainage: • For patients with external ventricular drain (EVD) inform neurosurgery if Start with goal ICP elevated deep sedation State Behavioral Scale (SBS) • If clamped, unclamp and place at 15 equal to -3 mmHg, do not raise if already lower then 15 mmHg • Recheck ICP every 10 minutes • Additional adjustments per Continue current ICP directed neurosurgery Yes Elevated ICP? No Therapies 24 hours. Then wean per pathway. Comfort Sedation • Richmond Agitation and Sedation Score (RASS) less than or equal to -1 Notify neurosurgery (NSYG), • Comfort score 17-24 trauma and Neurology critical • With a goal of preserving a care (NCC) neurologic exam and safety for the Neuromuscular Blockade patient Consider Repeat CT Scan Deep Sedation • Midazolam, fentanyl, or morphine • Avoid hypotension • Consider neuromuscular blockade if not ventilating or for refractory ICP Yes Elevated ICP? No Hyperosmolar Therapy • Hypertonic Saline (HTS) is first line in Maximize external ventricular Maximized patient with central venous line and drain (EVD) drainage and External ventricular not fluid overloaded Hyperosmolar therapy. drain (EVD) drainage No • 3% HTS may be administered via Discuss with Neurology if EEG and hyperosmolar remains reactive, if so could peripheral IV in emergent situations therapy? consider further sedation. Once neuromuscular blockade has • 12% (2mL/kg; Max=60mL) and 23.4% started, maintain sedatives and (1mL/kg; max=30mL) boluses via analgesics at current rate. central venous line for fluid Yes overloaded patients If greater than 3 PRN doses in 1 Consider Salvage Therapies via PICU and • Mannitol 0.5-1g/kg/dose IV if HTS not hour call PICU provider to discuss. Neurosurgery attending to attending call: available or refractory to HTS • Decompressive Craniectomy Continue sedation for ICP • Monitor sodium and osmolarity (Osm) • Hypothermia to 32-34⁰C management if effective. every 4 hours • Barbiturate Coma • Sodium less than 165 mmol/L and osmolarity less than 340 MOSM/Kg Page 2 of 15 CLINICAL PATHWAY TABLE OF CONTENTS Algorithm 1: Post Resuscitation Algorithm 2: ICP Management Target Population Background | Definitions Initial Evaluation & Clinical Management Therapeutics Systemic Management of Patients with Moderate/Severe Brain Injury Special Considerations for Suspected Abusive Head Trauma Richmond Agitation and Sedation Score (RASS) Appendix B: VTE Prophylaxis for TBI Algorithm References Clinical Improvement Team TARGET POPULATION Inclusion Criteria • All patients cared for at Children’s Hospital Colorado with known or suspected brain injury secondary to trauma with a post-resuscitation Glasgow Coma Score (GCS) of less than 8 (Severe Traumatic Brain Injury) or GCS 9-12 (Moderate Traumatic Brain Injury) with concern for potential decompensation. This includes patients less than 2 years of age with concern for abusive head trauma. Exclusion Criteria • Patient found down without clear trauma BACKGROUND | DEFINITIONS This protocol is based on “The Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents” and on the existing literature and is intended to provide standardization in the care of traumatic brain injury (TBI) patients at Children’s Hospital Colorado. Scope: Children’s Hospital Colorado – Anschutz Medical Campus (CHCO-Anschutz) Severe Traumatic Brain Injury: Glasgow Coma Score (GCS) of 3 – 8 Moderate TBI: GCS of 9-12 Mild TBI: GCS of 13-15 Page 3 of 15 CLINICAL PATHWAY INITIAL EVALUATION & CLINICAL MANAGEMENT Emergency Department Management: • Obtaining the best neurologic exam safely is critical for neurosurgical decision-making and appropriate patient management. In all patients, Glasgow Coma Scale (GCS) is assessed. When possible, consider avoiding further sedatives and paralytics until neurosurgery resident or fellow examines patient. Call neurosurgery early when sedation or intubation may be necessary. • When
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