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
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 about the little things that make a difference in TBI.
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!
Case Study 27 male 1x punch to head, LOC, hit ground. GCS 5/15 Intubated and sedated. Taken to the doughnut. Now what?
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!
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.
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
Once the big things are done:Its time to optimise: Pt Position Cervical collar Temperature BP Seizure prophylaxis Glucose
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!
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.
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 venous return!
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.
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)
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.
Seizure Prophylaxis Limited evidence to support practice!However: The injured brain thats seizing isn’t a good sign.Give prophylaxis: Phenytoin Levetiracetam (Keppra).
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
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!