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Management Of High  I C P And Traumatic Brain Injury
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Management Of High I C P And Traumatic Brain Injury

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  • 1. Management of Traumatic Head Injury
    • Dalhousie Critical Care Teaching Rounds
  • 2. Objectives
      • Know how to calculate CPP and the normal CPP range.
      • Discuss the management principles for raised ICP.
      • Discuss the issues for prevention of secondary injury in SAH including control of temperature, glucose control, prevention and treatment of vasospasm with nimodipine and HHH therapy.
      • Know how to work up and treat different Na disorders including SIADH, cerebral salt wasting and DI
  • 3. Neurophysiology
    • CPP = MAP – CIP
    • N= 50-70
    • Trauma
      • Increase volume of intracranial components
      • Loss of autoregulation
      • Increased CSF production
      • Hypercapnia and hypoxic insults
  • 4.  
  • 5. Management of Head Injury Emergency Diagnostic or Therapeutic Procedures Tracheal Intubation Fluid Resuscitation Ventilation/Oxygenation Sedation Severe Head Injury GCS≤8 ATLS Trauma Evaluation Deterioration Herniation CT Scan ICU ± Hyperventilate ± Mannitol Surgical Drainage
  • 6. Management of Raised ICP
    • First Line Rx
    Raised ICP>25mm Hg Measure ICP Maintain CPP>70 mm Hg Ventricular Drain Elevate HOB Normal Vent/Oxygenation Mannitol Sedation Raised ICP>25mm Hg CT
  • 7. Management of Raised ICP
    • Second Line Rx
    Raised ICP>25mm Hg Maintain CPP>70 mm Hg Furosemide Chemical Paralysis CSF Removal Vasopressor Barbiturates Hyperventilation Monitor S j O 2 Raised ICP>25mm Hg
  • 8. Head Injury
    • Primary Head Injury
      • Result of energy absorption
      • Difficult to prevent
      • Results from
        • neuronal or axonal disruption
        • shear
        • laceration
        • vascular disruption
    • Secondary Head Injury
      • Result of insults that occur after primary injury
      • Easier to prevent
      • Causes
        • ischemia
        • hypoxia
        • cerebral edema
        • intracranial hypertension
        • abnormalities of cerebral blood flow
        • metabolic derangements
  • 9. Role of ICP Monitoring
    • May help in earlier detection of intracranial mass lesions
    • Rationalizes therapy (ICP vs CPP)
    • CSF drainage
    • Helps in determining prognosis
    • May or may not improve outcome
    CPP=MAP-ICP
  • 10. ICP Monitors
    • Intraventricular Catheter
      • “ Gold standard”
      • Pros : Allows drainage of CSF (to dec ICP), allows “re-zeroing”
      • Cons : Invasive, difficult to insert, infection risk
    • Interparenchymal Probe
      • Pros : Low infection rate
      • Cons : Local pressure, “drift of zero”
  • 11. ICP Monitors
    • Subarachnoid Probe
      • Pros: Low infection rate, no brain penetration
      • Cons: Limited accuracy, high failure, requires flushing
    • Epidural Probe
      • Pros: Easy to insert, extra cranial
      • Cons: Limited accuracy, relatively delicate
    • Others:
      • Transcranial doppler
      • Tympanic membrane displacement
      • Lumbar CSF pressure
  • 12. Management of Traumatic Brain Injury Hypothermia Hypertonic Saline Neuro-protection Other Issues BP and Oxygen Indications for ICP CPP Mannitol Barbiturates Hyperventilation Glucocorticoids Guidelines Standards BTF and AANS Guidelines Process
  • 13. AANS & BTF Head Injury Guidelines (2000)
    • Past
      • Reliance on expert opinion
      • Documented variability of practice
    • Rely on scientific evidence and not expert opinion
    • Task force of experts with each Expert assigned a topic
      • Medline search
      • Review and grading of papers on topic
    • Multiple iterations
    • Involvement of national and international organizations
  • 14. Hyperventilation
    • CBF is the lowest in the first 24 hrs after injury
    • Hyperventilation decreases CBF (3%/torr)
      • Hypervent to a PCO2 26  CBF by 31% and CBV by 7%
    • Can  CBF and  A-VdO 2 to ischemic levels
    • Effect of hyperventilation transient (4 hours)
      • CBF 90% of control at 4 hours of hyperventilation
  • 15. Hyperventilation
    • Muizelaar et al 1991 RCT
    • Obrist et al 1984 Cohort study
      • Hyperventilation had a greater effect on CBF than ICP
    • Schnieder et al 1995 Cohort study
      • Hyperventilation second leading cause of jugular desaturation
    • Sioutos et al 1995 Cohort study
      • 1/3 of patients had CBF < 18 ml/100g/min
      • Hypervent decreased CBF further
    N= 77
  • 16. Xenon Perfusion CBF PCO 2 = 45 torr ICP = 44 mmHg CBF = 59 mL/min/100 gm PCO 2 = 30 torr ICP = 15 mmHg CBF = 14 mL/min/100 gm Skippen P et al: Crit Care Med 1997; 25:1402-1409
  • 17. Use of Hyperventilation
    • Standards
      • In absence of increased ICP chronic hyperventilation should be avoided (PCO2 < 25)
    • Guidelines
      • Use of prophylactic hyperventilation (PaCO2 < 35) should be avoided during the first 24 hrs after head injury because it may compromise CBF
    • Options
      • Hyperventilation may be necessary for brief periods when there is neurologic deterioration or for raised ICP refractory to standard therapy
  • 18.  
  • 19. Glucocorticoids
    • Useful in patients with brain tumor
    • Experimental evidence
      • Restoration of altered permeability in the lab
      • Reduced CSF production
      • Attenuation of free radical production
    • Meta analysis has showed no benefit
      • Alderson et al 1997
    • No benefit in clinical trial of
      • Tirilazad 17 amino steroid
        • N=1170 North America
        • N=1128 Europe
  • 20. CRASH Study
    • Head injury with GCS ≤ 14
    • Primary outcome
      • Death at 2 weeks
      • Disability at 6 months (not yet reported)
    • 10,008 subjects
    • Multicentre RCT Randomization groups
      • Placebo
      • Methylprednisolone
        • Load 2 gms
        • Maintenance 0.4 gm/hr for 47 hours
    • Mortality
      • Placebo 18%
      • Steroids 21%
    Lancet 2004; 364: 1321-38
  • 21. Glucocorticoids in Severe Head Injury
    • Standards
      • Not recommended for reducing ICP or improving outcome
  • 22. Blood Pressure and Oxygenation
    • TCDB study
      • Large prospectively collected data set
      • N=717
    • Anesthesia Study
      • Observational study of patients with severe head injury requiring surgery with in 72 hours of admission
      • N=53
    Death Chesnut et al 1997 Pietropaoli et al 1992 Outcome %
  • 23. Blood Pressure and Oxygenation
    • No class I evidence
    • Randomization probably not ethical
    • Standards
      • nil
    • Guidelines
      • Hypotension (SBP<90) and hypoxia (PO2<60)must be avoided and if present corrected immediately
    • Options
      • Mean arterial pressure > 90
      • CPP >70
  • 24. Rational for ICP Monitoring
    • Correlation between high ICP and poor outcome
    • Intracranial hypertension more likely in those with CT abnormalities or adverse features
      • Age >40
      • Motor posturing
      • SBP<90
    Narayan et al 1982
  • 25. Intracranial Pressure Monitoring
    • Standards
      • nil
    • Guidelines
      • Indicated for severe head injury with abnormal CT
      • Indicated for severe head injury with normal CT with 2 or more of
        • age greater than 40
        • motor posturing
        • Systolic BP less than 90 mm Hg
      • Not indicated for mild or moderate head injury
  • 26. Does ICP Monitoring Improve Outcome
    • No randomized controlled trial
      • Improved outcome with ICP monitoring over historical data
      • Saul and Ducker 1982 (Class II)
        • Rx ICP 20-25  mortality 46%
        • Rx ICP >15  mortality 28%
      • Eisenberg et al 1988 (Class I)
        • Better outcome if ICP responded to Pentobarb
      • Colohan et al 1989 (Class II)
        • 2 centers with lower mortality in center with ICP monitoring
    Groups managed at different time periods Other confounding factors
  • 27. Does ICP Monitoring Improve Outcome
    • No randomized controlled trial
      • Ghajar et al 1995 (Class III)
        • Meta analysis demonstrating decreased mortality with CSF drainage
      • Lane et al 2000 (Class II)
        • Retrospective study of trauma database
        • 5507 head injured patients
        • Used AIS scores to define injury
        • Results
          • multivariate analyses controlling for AIS head, ISS and injury mechanism indicated that ICP monitoring was associated with significantly improved survival (p < 0.015)
  • 28. Cerebral Perfusion Pressure
    • CBF low following head injury
      • Compression of cerebral vessels
      • Reduced cerebral metabolism
      • Vasospasm
    • CBF lowest first 24 hrs after injury
    • Ischemia common at autopsy
    • Correlation with CBF, GCS and outcome
    • Failure to maintain adequate CPP may lead to increased ICP and poor outcome
  • 29. Physiology
    • ICP, CPP, CBF and CMRO2
    • CPP = MAP – ICP (or CVP) ‏
    • Monroe-Kellie Doctrine
  • 30. Cerebral Perfusion Pressure
    • Fortune et al 1994 (Class II) N=14
      • CPP maintained above 70 mm Hg
      • Mortality 14%
    • Rosner et al 1990 (Class II) N= 34
      • CPP kept above 70 mm Hg
      • Mortality 21%, good outcome 68%
    • Bruce et al 1973 (Class II) N=14
      • Study of the effect of increasing the blood pressure on ICP
      • When BP increased by 30 mm Hg, ICP increased by 5 mm Hg
    • Robertson et al 1999 (Class I) N=189
      • Comparison of ICP vs CPP targeted therapy
      • Fewer SVO 2 episodes in CPP targeted group
      • No difference in GOS, ICP, Higher ARDS in CPP targeted group
  • 31. Guidelines for Cerebral Perfusion Pressure
    • Standards
      • nil
    • Guidelines
      • CPP maintained at a minimum of 60 mm Hg
  • 32. Mannitol
    • No controlled trials with placebo
    • Mechanism of action (Early vs Late)
      • Plasma volume expansion
        • reduces blood viscosity
        • increases CBF
        • increases cerebral oxygen delivery
      • Osmotic gradient
    • Circulating mannitol may cross BBB
      • avoid continuous administration
      • contraindicated in renal failure
  • 33. Mannitol
    • Schwartz et al 1984 (Class I) N=59
      • Mannitol group had lower outcome mortality in DAI
        • 41% vs 77%
      • Better CPP in mannitol group
    • Fortune et al 1995 (Class II) N=22
      • Studied effect of mannitol and hyperventilation on S JV O 2
      • 196 interventions on 22 patients
      • S JV O 2 increased with mannitol and decreased with hyperventilation
  • 34. Mannitol Use in Severe Head Injury
    • Standards
      • nil
    • Guidelines
      • Mannitol effective for control of ICP after severe head injury
      • 20 percent solution
      • 0.25 to 1 g/kg IV bolus
      • Repeat doses can be administered every six to eight hours
    • Options
      • indications transtentorial herniation and neurologic deterioration not attributable to systemic pathology
      • Serum osmolarity kept < 320
      • Maintain euvolemia
      • Intermittent boluses may be more effective than continuous infusion
  • 35. Barbiturates
    • Lower ICP
    • Mechanisms
      • alterations of vascular tone
      • suppression of metabolism
      • inhibition of free radical lipid peroxidation
      • coupling of CBF to metabolic demands
    • Assumptions
      • Can effect long term ICP control when other treatments have failed
      • Absolute ICP control improve outcome
  • 36. Barbiturates
    • 3 randomized control trials
      • 2 prophylactic trials showed no benefit
      • 1 raised intracranial pressure therapeutic trial showed improved survival if ICP responded to barbiturates
  • 37. Schwartz et al (1984)
    • Barbiturates with mannitol for initial therapy for increased ICP
    • Randomized when ICP>25 mm Hg for more than 15 minutes
    N=59 Mortality
  • 38. Eisenberg et al (1988)
    • Control of ICP primary outcome
    • Randomized to barbiturates or control n=73
    • Treatment failure in control arm resulted in barbiturates
    • Survival 92% if ICP responded to barbiturates vs 17% if no ICP response
    ICP Control %
  • 39. Barbiturate Use in Severe Head Injury
    • Standards
      • nil
    • Guidelines
      • Barbiturates may be considered
        • hemodynamically stable
        • salvageable head injury
        • refractory intracranial hypertension
  • 40. Hypothermia
    • Use supported by;
      • Animal data
      • Single centre trials
      • Success in related conditions global cerebral hypoxia
    • One Multi-centre RCT (NABISH)
      • NEJM 2001; 344: 556-63
      • N=368
      • Target temp 33
      • Hypothermia for 48 hours
  • 41. Temperature Control and Induced Hypothermia
    • Most effective method for brain protection
      • decreases both basal and electrical metabolic requirements
      • CMR decreases by 6% to 7%/°C
      • metabolic requirements continue to decrease even after electrical silence
  • 42. NABISH Results NEJM 2001; 344: 556-63
      • Hypothermia
        • More hospital days with complications
        • Lower ICP
    • Criticisms
      • Accepted MAP of 50
      • Slow cooling
      • Rapid and active rewarming
  • 43. But Food for Thought…
    • JAMA 2003 Jun 11;289(22):2992-9.
    • Prolonged therapeutic hypothermia after traumatic brain injury in adults: a systematic review.
    • Meta-analysis of 12 rct
    • Decreased risk of death RR0.81 and poor neurologic outcome RR0.78
    • Prolonged duration of hypothermia seemed better
  • 44. Hypertonic Saline
    • Potential advantages
      • Quicker management of hypotension
      • Osmotic dehydration lower ICP
      • WBC immunomodulation
      • May decrease glutamate
    • Earlier studies suggested a mortality benefit and lower ICP
    • Meta-analysis demonstrated improved survival rates, especially in head trauma (38% versus 27%)
      • Wade CE, Kramer GC, Grady JJ, et al. Efficacy of hypertonic 7.5% saline and6%dextran-70 in treating trauma: a meta-analysis of controlled clinical studies. Surgery 1997;122:609–16.
    • Cooper et al JAMA 2004
      • Prehospital admin of 250 ml 7.5% HS vs RL
      • RCT 229 subjects
      • 6 mos GOS main outcome
      • No difference in GOS or survival
      • Trend to lower ICP with HS
  • 45. SAFE trial
    • Subgroup analysis of trauma patients with severe brain injury
    • 460 patients
    • Mortality higher in albumin group 33.2% vs. 20.4 saline group
    • Saline or Albumin for Fluid Resuscitation in Patients with Traumatic Brain InjuryN Engl J Med 2007;357:874-84.
  • 46. Other stuff to consider
    • Decompressive craniectomy
    • Antieplileptic therapy
    • Management of fever
    • Position
    • Treatment of hypertension
      • ICP >20 and CPP>160
    • Fluid/electrolyte
      • Osmolarity should be 280-305
      • Avoid hyponatremia
      • Hypertonic saline in mannitol resistant ICP
  • 47. Summary
    • Avoid hypotension and hypoxia
    • Maintain CPP
    • Hyperventilation should only be undertaken with herniation or appropriate monitoring of CPP and cerebral oxygenation