Acute Management of Traumatic Brain Injury

Home , Diffuse axonal injury, Intracranial hemorrhage, Traumatic brain injury

David Chesler, MD PhD Assistant Professor of Neurological Surgery and Pediatrics Co-Director of Pediatric Neurosurgery Department of Neurological Surgery Stony Brook University School of Medicine

Traumatic Brain Injury No Financial Disclosures

Traumatic Brain Injury Teaching Objectives

• Describe the initial physical assessment and pertinent radiographic studies to evaluating a patient suspected of having a traumatic brain injury • Describe the indications for placement of an invasive Intracranial Pressure Monitor • Discuss the medical management of acute intracranial hypertension in TBI patients • Discuss the role for surgical intervention in the management of acute TBI

Traumatic Brain Injury Overview of Traumatic Brain Injury • Approximately 1.7 million people with TBI annually • Contributes to 30.5% of all injury- related deaths in the US • Around 75% of TBI are mild forms of TBI • In 2000, the annual direct and indirect cost of TBI in the US was estimated at $60 billion source: https://www.cdc.gov/traumaticbraininjury/pdf/bluebook_factsheet -a.pdf

Traumatic Brain Injury Overview of Traumatic Brain Injury • Falls are leading cause of TBI with highest rates in children age 0-4 and adults > 75 • Falls account for the highest frequency of TBI-related emergency room visits • MVAs are the leading cause of TBI-related deaths; rates are highest in adults 20-24 source: https://www.cdc.gov/traumaticbraininjury/pdf/bluebook_factsheet -a.pdf

Traumatic Brain Injury Vocabulary of TBI

• Glasgow Coma Score • mild 13-15 • moderate 9-12 • severe 3-8

Traumatic Brain Injury Vocabulary of TBI • Types of Intracranial Injuries • Intracranial hemorrhage • subdural hematoma • epidural hematoma • intraparenchymal hematoma • diffuse axonal injury or shear injury • Fractures • open vs closed • displaced vs non-displaced

Traumatic Brain Injury Initial Assessment of TBI patient • A airway • B breathing • C circulation • Glasgow coma scale (GCS) • Neurological function • ASIA Motor Score for patients with suspected spinal cord injury able to participate • Imaging - Depends on mechanism of injury • CT brain is gold standard for initial assessment of TBI • MRI more important is assessment of CT occult imaging or prognostic evaluation • Labs • CBC, CMP, PT/INR/PTT, ARU/PRU, T&S, Tox/EtOH, Lactate, ABG

Traumatic Brain Injury Management of Traumatic Brain Injury Medical Surgical • Ventilation • ICP monitoring • BP control • bolt vs ventriculostomy • Manipulate Serum Osmolarity • CSF diversion • Sedation and Analgesia • ventriculostomy vs lumbar drain • Normothermia • Seizure prophylaxis • Craniotomy/Evacuation • Correction of Coagulopathy • Decompressive Craniectomy

Traumatic Brain Injury Seizure Prophylaxis • AEDs for 7 days in patients with CT positive TBI • SDH, SAH, ICH, not EDH • Dilantin (phenytoin) or Cerebryx (fosphenytoin) recommended • Keppra (levetiracetam) widely used however no data to support use over dilantin

• Use of AEDs shown to reduce incidence of seizure initially following injury but has no effect on long-term risk of seizure. • If seizure in first 7 days, recommendation is for continuation of AEDs for at least three months with reassessment by neurology at that time to determine ongoing therapy. source: Carney et al. 2016. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery

Traumatic Brain Injury Correction of Coagulopathy • All antiplatelet and anticogulation agents should be held and coagulopathy reversed. • Antiplatelet agents are reversed through “time” and the administration of platelets • Remember that any “onboard” agents will affect administered platelets • Coumadin • FFP, Cryoprecipitate, Activated Factor VII (NovoSeven), PCC or activated PCC (e.g. Kcentra) can all be used depending on institutional practices and individual patient considerations. • NOACs • Reversal is dependent on agent in question, most often PCC or activated PCC is recommended • Specific antidotes do exist for some (e.g. Praxabind) • Recommend involvement of hematology EARLY to facilitate appropriate reversal

Traumatic Brain Injury Sedation and Analgesia • Use of sedating medications should be used with caution. • Must balance indications for sedation or analgesia with need to maintain ability to obtain neurologic examination. • Sedation is not the same as controlling blood pressure (unless hypertension is directly related to agitation)

• Continuous infusion of SHORT acting medications for sedation • propofol – first line agent; check daily lactate and myoglobin to assess for development of propofol infusion syndrome • fentanyl – first line agent • versed • dexmetomidine (Precedex) - can be used in lieu of propofol in pediatric patients or in cases of PIS however not as effective for sedation or ICP control • Barbiturates are reserved for the treatment of intracranial hypertension REFRACTORY to surgical and conventional medical therapy

Traumatic Brain Injury Ventilation • In patients with poor GCS, consider intubation for airway protection and respiratory support • In the absence of intracranial hypertension, normocarbia should be maintained.

(PaCO2 30-40) • Hyperventilation should be avoided in the initial 24h after injury. (Can compromise cerebral blood flow) • Hyperventilation can be used as a temporizing measure in the management of intracranial hypertension.

(PaCO2 maintained > 25) • Early tracheostomy can be considered for reduction in incidence of VAP if felt patient unlikely to promptly wean from mechanical ventilation (and perceived benefit outweighs risk) source: Carney et al. 2016. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery

Traumatic Brain Injury Normothermia • Aggressively treat febrile state • Increased body temperature results in increased cerebral metabolism which can contribute to secondary injury • Treatment is through direct cooling, antipyretics and treating underlying cause if known (e.g. Infection) • No data to support the use of early or short-term hypothermia in the treatment of diffuse TBI

source: Carney et al. 2016. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery

Traumatic Brain Injury Medical Management of ICP – The Basics •Monro–Kellie Doctrine : TV = CSF + blood+ brain •Normal ICP (mmHg) • adult 0-15 (upper limit of normal is 20) • young children 3-7 • infants 0-6 •CPP = MAP – ICP • Goal CPP is ADULT ~60-70 • Goal CPP in PEDIATRIC >50-55 • CPP should not be necessarily chased by pushing MAP in patients with cerebral dysregulation

source: Carney et al. 2016. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery

source: http://aneskey.com/increased-intracranial-pressure-2/

Traumatic Brain Injury Hyperosmolar Therapy for Intracranial Hypertension • Works on the premise of "drawing" free water out of the brain into the intravascular compartment. • Medications are typically administered in periodic boluses • Though some centers use continuous infusions, there is no data to support this practice over bolus therapy. • Mannitol • Dosed as 0.5-1g/kg IV q6h • Dehydrates brain thereby lowering ICP but ALSO acts a diuretic which can deplete the intravascular volume which can cause HYPOTENSION. • Hypertonic Saline (HTS) • Dosed as 250-500ml of 3% NaCl, 150ml of 7.5% NaOAc or 30ml of 23.4% NaCl • Decision as to which "flavor" of HTS used based on institutional culture as well as systematic evaluation of volume status, serum pH and goal of therapy.

Traumatic Brain Injury Intracranial Pressure (ICP) Monitoring • Intracranial pressure (ICP) should be monitored in all salvageable patients with a severe traumatic brain injury (TBI) (GCS 3-8 after resuscitation) and an abnormal computed tomography (CT) scan. An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns.

• ICP monitoring is indicated in patients with severe TBI with a normal CT scan if two or more of the following features are noted at admission: age over 40 years, unilateral or bilateral motor posturing, or systolic blood pressure (BP) <90 mm Hg. source: Carney et al. 2016. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery

Traumatic Brain Injury Intracranial Pressure (ICP) Monitoring • Several options to accomplish this with most common being: • Intraparenchymal pressure monitor –often referred to as a Camino Bolt ICP monitor • External Ventricular Drain (EVD) or Ventriculostomy

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Traumatic Brain Injury Surgical Intervention • Surgery in TBI is aimed at relief of intracranial hypertension and compression of brain structures. • Does not restore function to directly damaged brain parenchyma.

Traumatic Brain Injury

Traumatic Brain Injury Decompressive Craniectomy

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Traumatic Brain Injury