Resuscitating the    Injured Brain     “It’s the little things that matter”                       By Kane Guthrie
Learning Points How to resuscitate the injured brain. A case. Understanding of primary Vs secondary injury. Learn abou...
Traumatic Brain Injury Leading cause of death in children and young adults! Main cause of lifelong disability after trau...
Case Study 27 male 1x punch to head, LOC, hit  ground. GCS 5/15 Intubated and sedated. Taken to the doughnut. Now wh...
The PathO!          Primary                           Secondary Physical damage to                Complex process.  pare...
The Types          Primary                       SecondaryExtra-axial:                   Acute: Epidural haematoma       ...
The @ risk groups! The Elderly Infants The anticoagulated Chronic alcoholics
The other Lethal Triad!          or  or
Our Goals in ED Resuscitate & assess for other injuries. Prevent & treat raised ICP & secondary brain insults. Avoid hy...
The Big ThingsFocus on correcting/preventing secondary brain insults: Avoid Hypoxia and Hypotension Prevent ∧ICP & impai...
The Algorithm
The Little Things!!
Once the big things are done:Its time to optimise: Pt Position Cervical collar Temperature BP Seizure prophylaxis Gl...
Patient Position Elevate the head of bed to 30-45°C. Decreases ICP by:   Displacing the CSF.   Increasing venous outfl...
Trendelenburg Position. Time honored tradition for the hypotensive Pt. More harm than good. May give transient rise in ...
Securing the Tube Tape Vs Ties Ties can constrict venous  return and raise ICP. Best to avoid!
Cervical Collar AKA the “BRAIN TOURNIQUET” Removal ∨ ICP by 2-5 mmHg. If unable to remove – loosen enough so it aids ve...
Temperature Mx Therapeutic hypothermia – no good evidence yet. (POLAR  study just starting) Fever is bad :   ∧ oxygen c...
Blood Pressure Mx Abnormal BP is common! Hypotension = detrimental & needs to be treated  aggressively – maintain CPP. ...
Cerebral Perfusion Pressure CPP = MAP – ICP. Elevated ICP - leads to loss of CPP – leading irreversible  brain damage. ...
Seizure Prophylaxis Limited evidence to support practice!However: The injured brain thats seizing isn’t a good sign.Give...
Glucose Mx Controversial topic in critical care! Hyperglycaemia in TBI generally = poor neuro function. Hypoglycaemia i...
In Summary1. Avoid hypotension & hypoxia at all cost!2. Sit them up decreases ICP & VAP!3. Keep a close eye on the BP, BSL...
RememberWhat YOU do matters!                   Mel Herbert.
But!
Resuscitating the injured brain
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Resuscitating the injured brain

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Emergency nursing talk on resuscitating the injured brain- focusing on the little things- that make a difference to morbidity and mortality.

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  • The Elderly – cerebral atrophy, risk of falls.Infants – large head side, compressible skull, risk of NAI.Chronic alcoholics – liver failure induce coagulopathy, cerebral atrophy
  • Obligate = needs to survive with!
  • Head trauma still carries a high mortality!
  • Resuscitating the injured brain

    1. 1. Resuscitating the Injured Brain “It’s the little things that matter” By Kane Guthrie
    2. 2. Learning Points How to resuscitate the injured brain. A case. Understanding of primary Vs secondary injury. Learn about the little things that make a difference in TBI.
    3. 3. Traumatic Brain Injury Leading cause of death in children and young adults! Main cause of lifelong disability after trauma! Optimal early Mx can have profound effect on their prognosis! What we do downstairs can make the difference upstairs!
    4. 4. Case Study 27 male 1x punch to head, LOC, hit ground. GCS 5/15 Intubated and sedated. Taken to the doughnut. Now what?
    5. 5. The PathO! Primary Secondary Physical damage to  Complex process. parenchyma.  Results from primary injury Occurs during traumatic event. and acute disorder that occur Results in from this. shearing/compression of brain 1. Hypotension tissue. 2. Hypoxia 3. Hypo/Hypercarbia Not Reversible!  Preventable and reversible!
    6. 6. The Types Primary SecondaryExtra-axial: Acute: Epidural haematoma  Diffuse cerebral swelling Subdural haematoma  Brain herniation SAH  Infarction Intraventricular Haematoma  InfectionIntra-axial: Chronic: Axonal injury  Hydrocephalus Cortical contusion  CSF leak ICH
    7. 7. The @ risk groups! The Elderly Infants The anticoagulated Chronic alcoholics
    8. 8. The other Lethal Triad! or or
    9. 9. Our Goals in ED Resuscitate & assess for other injuries. Prevent & treat raised ICP & secondary brain insults. Avoid hypoxia & hypotension. Preservation of CPP. Optimisation of cerebral oxygenation.
    10. 10. The Big ThingsFocus on correcting/preventing secondary brain insults: Avoid Hypoxia and Hypotension Prevent ∧ICP & impaired cerebral perfusion Reverse anticoagulation Protect and secure airway Rule out C-spine injuries
    11. 11. The Algorithm
    12. 12. The Little Things!!
    13. 13. Once the big things are done:Its time to optimise: Pt Position Cervical collar Temperature BP Seizure prophylaxis Glucose
    14. 14. Patient Position Elevate the head of bed to 30-45°C. Decreases ICP by:  Displacing the CSF.  Increasing venous outflow. Also decrease risk of VAP! Use reverse trendelenburg if cervical spine an issue!
    15. 15. Trendelenburg Position. Time honored tradition for the hypotensive Pt. More harm than good. May give transient rise in BP.But: Raise’s ICP through venous congestion. Worsen hypotension pushing abdo organs in thorax decrease venous return to heat. Alter ventilation & perfusion.
    16. 16. Securing the Tube Tape Vs Ties Ties can constrict venous return and raise ICP. Best to avoid!
    17. 17. Cervical Collar AKA the “BRAIN TOURNIQUET” Removal ∨ ICP by 2-5 mmHg. If unable to remove – loosen enough so it aids venous return!
    18. 18. Temperature Mx Therapeutic hypothermia – no good evidence yet. (POLAR study just starting) Fever is bad :  ∧ oxygen consumption  ∧ cerebral metabolic rate. We SHOULD focus on therapeutic normothermia! Monitor closely and keep temp <37°C.
    19. 19. Blood Pressure Mx Abnormal BP is common! Hypotension = detrimental & needs to be treated aggressively – maintain CPP. Hypertension can occur due to raised ICP, medical condition, or pain & anxiety. Use sedative/analgesia first line if intubated. Rarely use short acting antiHT and dose gingerly to avoid hypotension and ∨CPP. (Archives of Surg 2001:136;1118-1123)
    20. 20. Cerebral Perfusion Pressure CPP = MAP – ICP. Elevated ICP - leads to loss of CPP – leading irreversible brain damage. Difficult to measure ICP & CPP in the ED. Focus on avoiding hypoxia and hypotension. Aim for Spo2>90 & BP> 90 with target MAP >70mmHg gives you an estimate of CPP of around 50-70mmHg.
    21. 21. Seizure Prophylaxis Limited evidence to support practice!However: The injured brain thats seizing isn’t a good sign.Give prophylaxis: Phenytoin Levetiracetam (Keppra).
    22. 22. Glucose Mx Controversial topic in critical care! Hyperglycaemia in TBI generally = poor neuro function. Hypoglycaemia is bad – brain obligate glucose consumer. Studies show intensive insulin therapy - more hypo’s & ?increase mortality.Take home point: Treat Pt’s with marked hyperglycaemia but avoid hypoglycaemia. Aim for BSL 8-12mm0L
    23. 23. In Summary1. Avoid hypotension & hypoxia at all cost!2. Sit them up decreases ICP & VAP!3. Keep a close eye on the BP, BSL & Temp!4. Try and clear the neck early and tape the tube!
    24. 24. RememberWhat YOU do matters!  Mel Herbert.
    25. 25. But!

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