Dr. Ignacio J. PreviglianoDr. Ignacio J. Previgliano
Unidad de Terapia IntensivaUnidad de Terapia Intensiva
Hospital Gral....
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
The European Brain Injury Consortium.The European Brain ...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
EpidemiologyEpidemiology

Study designs.Study designs.
...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
ATLS ProceduresATLS Procedures
A:A: Airway with cervical...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
GCSGCS
(After resuscitation)(After resuscitation)
GCS < ...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Glasgow 9 - 13
Clinical observation 48 hs, CT and
neuros...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Gidelines for the management ofGidelines for the managem...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Classification of evidenceClassification of evidence
Cla...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Trauma systemsTrauma systems
Guidelines:Guidelines:
All ...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Initial managementInitial management
Severe Head InjuryS...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Resuscitation of blood pressureResuscitation of blood pr...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
 Differences in the incidence of hypoxia and hypotension...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
GOS according to the presence ofGOS according to the pre...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
0%
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GOS 4-5 GOS 2-3 GOS 1...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
0%
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Total (699) In...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Indications for intracranialIndications for intracranial...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Intracranial pressure monitoringIntracranial pressure mo...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Intracranial pressureIntracranial pressure
treatment thr...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Recommendations for intracranialRecommendations for intr...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Guidelines for cerebralGuidelines for cerebral
perfusion...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
CPP and outcomeCPP and outcome
66
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70
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8...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Effectiveness of raising CPP withEffectiveness of raisin...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Effectiveness of head positionEffectiveness of head posi...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
HyperventilationHyperventilation
StandardStandard
In the...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
The effect of hyperventilationThe effect of hyperventila...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Use of MannitolUse of Mannitol
GuidelinesGuidelines
Mann...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Effectiveness of mannitol 0.5Effectiveness of mannitol 0...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Use of barbiturates in the controlUse of barbiturates in...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Role of steroidsRole of steroids
Standard:Standard:
The ...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Use of steroidsUse of steroids
0%
10%
20%
30%
40%
50%
60...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
MonitoringMonitoring
(49)(49)
MonitoringMonitoring
(49)(...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
NutritionNutrition
Guidelines:Guidelines:
Replace 140% o...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
Role of antiseizure prophylaxisRole of antiseizure proph...
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Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
0% 20% 40% 60% 80%
1987
1990
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Hospital Fer...
IJP´01IJP´01
Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
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  1. 1. Dr. Ignacio J. PreviglianoDr. Ignacio J. Previgliano Unidad de Terapia IntensivaUnidad de Terapia Intensiva Hospital Gral. de Agudos J.A. FernándezHospital Gral. de Agudos J.A. Fernández Brain Injury SymposiumBrain Injury Symposium Management of Moderate and SevereManagement of Moderate and Severe Head InjuriesHead Injuries
  2. 2. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD The European Brain Injury Consortium.The European Brain Injury Consortium. Nemo solus satis sapit: nobody knowsNemo solus satis sapit: nobody knows enough alone.enough alone. Acta Neurochir (Wien). 1997;139(9):797-803Acta Neurochir (Wien). 1997;139(9):797-803 With globalization, goods, capital, culture,With globalization, goods, capital, culture, and knowledge readily diffuse acrossand knowledge readily diffuse across borders, but political and social institutionsborders, but political and social institutions often lag a step behind.often lag a step behind. Infection and inequalities: TheInfection and inequalities: The modern plagues. Farmer P (ed). Berkley: Universityof California Press, 1999modern plagues. Farmer P (ed). Berkley: Universityof California Press, 1999
  3. 3. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD EpidemiologyEpidemiology  Study designs.Study designs.  Developed and developing countriesDeveloped and developing countries reality.reality.  Frontiers between rich and poor in eachFrontiers between rich and poor in each society.society.  Urban and rural enviromentUrban and rural enviroment  Sanitary organizationSanitary organization
  4. 4. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD ATLS ProceduresATLS Procedures A:A: Airway with cervical spine controlAirway with cervical spine control B:B: BreathingBreathing C:C: Circulation (MAP and capillar refill)Circulation (MAP and capillar refill) D:D: Neurological deficit (GCS)Neurological deficit (GCS)
  5. 5. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD GCSGCS (After resuscitation)(After resuscitation) GCS < 8GCS < 8 GCS > 8GCS > 8 PupillaryPupillary asimetryasimetry IsocoriaIsocoria IntubationIntubation HVHV MannitolMannitol (0.25 a 0.5(0.25 a 0.5 mg/kg/bolo)mg/kg/bolo) CT ?CT ? NeurosurgeryNeurosurgery IntubationIntubation CTCT ICUICU NeurosurgeryNeurosurgery GCS 9 - 13GCS 9 - 13 GCS 14 -15GCS 14 -15 CTCT Intensive -Intensive - IntermediateIntermediate CareCare Neurosurgery?Neurosurgery? ItalianItalian GuidelinesGuidelines for Minorfor Minor Head InjuryHead Injury
  6. 6. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Glasgow 9 - 13 Clinical observation 48 hs, CT and neurosurgical consultation No intracranialNo intracranial lesionlesion No intracranialNo intracranial lesionlesion IntracranialIntracranial lesionlesion IntracranialIntracranial lesionlesion New CT in 48 hsNew CT in 48 hsNew CT in 48 hsNew CT in 48 hs TCDB IIITCDB III TemporalTemporal ContusionContusion TCDB IIITCDB III TemporalTemporal ContusionContusion TCDB I - IITCDB I - II ContusionContusion TCDB I - IITCDB I - II ContusionContusion NICU ICPNICU ICPNICU ICPNICU ICP NINCUNINCU Hourly GCSHourly GCS NINCUNINCU Hourly GCSHourly GCS
  7. 7. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Gidelines for the management ofGidelines for the management of severe traumatic brain injurysevere traumatic brain injury Trauma Systems Initial management Resuscitation of blood pressure and oxygenation Indications for intracranial pressure monitoring Intracranial pressure treatment threshold Recommendations for intracranial pressure monitoring technology Guidelines for cerebral perfusion pressure Hyperventilation Hyperventilation Use of mannitol Use of barbiturates in the control of intracranial hypertension Rol of steroids Critical pathway for the treatment of established intracranial hypertension Nutrition Rol of antiseizure prophylaxis following head injury
  8. 8. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Classification of evidenceClassification of evidence Class I evidence:Prospective randomized controlled trials , the (Standards) gold standard of clinical trials. However some may be poorly designed, lack sufficient patient numbers or suffer from other methodological inadequacies. Class II evidence: Clinical studies in which the data was (Guidelines) collected prospectively, and retrospective analyses that were based on clearly reliable data (observational, cohort, prevalence and case control studies) Class III evidence: Most studies based on retrospectively collected (Options) data (clinical series, databases or registries, case reviews, case report) Expert opinion. Class I evidence:Prospective randomized controlled trials , the (Standards) gold standard of clinical trials. However some may be poorly designed, lack sufficient patient numbers or suffer from other methodological inadequacies. Class II evidence: Clinical studies in which the data was (Guidelines) collected prospectively, and retrospective analyses that were based on clearly reliable data (observational, cohort, prevalence and case control studies) Class III evidence: Most studies based on retrospectively collected (Options) data (clinical series, databases or registries, case reviews, case report) Expert opinion.
  9. 9. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Trauma systemsTrauma systems Guidelines:Guidelines: All regions should have an organized trauma care systemAll regions should have an organized trauma care system Options:Options: Neurosurgeons should have an organized and responsive system of care for patients withNeurosurgeons should have an organized and responsive system of care for patients with neurotrauma. They should initiate neurotrauma care planning, including pre-hospitalneurotrauma. They should initiate neurotrauma care planning, including pre-hospital management and triage, direct trauma center transport, maintain appropriate call schedules,management and triage, direct trauma center transport, maintain appropriate call schedules, review trauma care records for quality improvement and participate in trauma educationreview trauma care records for quality improvement and participate in trauma education programsprograms Trauma facilities treating neurotrauma must have a neurosurgery service, an in-house traumaTrauma facilities treating neurotrauma must have a neurosurgery service, an in-house trauma surgeon, a continuously staffed and available operating room, intensive care unit andsurgeon, a continuously staffed and available operating room, intensive care unit and laboratory. A CT scanner must be immediately available.laboratory. A CT scanner must be immediately available. In rural or weather-bound communities without a neurosurgeon, a surgeon should be trained toIn rural or weather-bound communities without a neurosurgeon, a surgeon should be trained to perform accurate neurological assessment, including training to perform life-saving surgicalperform accurate neurological assessment, including training to perform life-saving surgical treatment of an extracerebral hematoma in a deteriorating patient.treatment of an extracerebral hematoma in a deteriorating patient. Guidelines:Guidelines: All regions should have an organized trauma care systemAll regions should have an organized trauma care system Options:Options: Neurosurgeons should have an organized and responsive system of care for patients withNeurosurgeons should have an organized and responsive system of care for patients with neurotrauma. They should initiate neurotrauma care planning, including pre-hospitalneurotrauma. They should initiate neurotrauma care planning, including pre-hospital management and triage, direct trauma center transport, maintain appropriate call schedules,management and triage, direct trauma center transport, maintain appropriate call schedules, review trauma care records for quality improvement and participate in trauma educationreview trauma care records for quality improvement and participate in trauma education programsprograms Trauma facilities treating neurotrauma must have a neurosurgery service, an in-house traumaTrauma facilities treating neurotrauma must have a neurosurgery service, an in-house trauma surgeon, a continuously staffed and available operating room, intensive care unit andsurgeon, a continuously staffed and available operating room, intensive care unit and laboratory. A CT scanner must be immediately available.laboratory. A CT scanner must be immediately available. In rural or weather-bound communities without a neurosurgeon, a surgeon should be trained toIn rural or weather-bound communities without a neurosurgeon, a surgeon should be trained to perform accurate neurological assessment, including training to perform life-saving surgicalperform accurate neurological assessment, including training to perform life-saving surgical treatment of an extracerebral hematoma in a deteriorating patient.treatment of an extracerebral hematoma in a deteriorating patient.
  10. 10. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Initial managementInitial management Severe Head InjurySevere Head Injury (GCS 8 or less)(GCS 8 or less) Severe Head InjurySevere Head Injury (GCS 8 or less)(GCS 8 or less) ATLSATLS EvaluationEvaluation ATLSATLS EvaluationEvaluation Emergency diagnosticEmergency diagnostic or therapeuticor therapeutic procedures as indicatedprocedures as indicated Emergency diagnosticEmergency diagnostic or therapeuticor therapeutic procedures as indicatedprocedures as indicated IntubationIntubation 52 patients52 patients Ventilation (PCOVentilation (PCO22 ca 35)ca 35) 16 pleural drainages16 pleural drainages Fluid resuscitation 2228Fluid resuscitation 2228 ml crystalloids 1350ml crystalloids 1350 ml colloidsml colloids OxygenationOxygenation SedationSedation (midazolam 52 patients)(midazolam 52 patients) Neuromuscular paralysisNeuromuscular paralysis (pancuronion 47 patients)(pancuronion 47 patients) IntubationIntubation 52 patients52 patients Ventilation (PCOVentilation (PCO22 ca 35)ca 35) 16 pleural drainages16 pleural drainages Fluid resuscitation 2228Fluid resuscitation 2228 ml crystalloids 1350ml crystalloids 1350 ml colloidsml colloids OxygenationOxygenation SedationSedation (midazolam 52 patients)(midazolam 52 patients) Neuromuscular paralysisNeuromuscular paralysis (pancuronion 47 patients)(pancuronion 47 patients) Hyperventilation (8)Hyperventilation (8) Mannitol (1 g/kg) (7)Mannitol (1 g/kg) (7) Hyperventilation (8)Hyperventilation (8) Mannitol (1 g/kg) (7)Mannitol (1 g/kg) (7) CTCT 52 patients52 patients CTCT 52 patients52 patients NoNo SurgerySurgery (20)(20) SurgerySurgery (20)(20) YesYes ICUICU ICP monitoringICP monitoring 49 patients49 patients ICUICU ICP monitoringICP monitoring 49 patients49 patients YesYesHerniation?Herniation? Deterioration?Deterioration? Surgical lesion?Surgical lesion? Resolution?Resolution? YesYes
  11. 11. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Resuscitation of blood pressureResuscitation of blood pressure and oxygenationand oxygenation Guidelines:Guidelines: Hypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaOHypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaO22 < 90%) must be avoided and scrupulously avoided, if possible, or< 90%) must be avoided and scrupulously avoided, if possible, or corrected immediately in severe TBI patients.corrected immediately in severe TBI patients. Options:Options: The MAP should be maintained above 90 mmHg through theThe MAP should be maintained above 90 mmHg through the infusion of fluids throughout the patient’s course to attempt toinfusion of fluids throughout the patient’s course to attempt to maintain CPP > 70 mmHg. Patients with GCS < 9 who are unable tomaintain CPP > 70 mmHg. Patients with GCS < 9 who are unable to maintain their airway or who remain hypoxemic despitemaintain their airway or who remain hypoxemic despite supplemental O2 required that their AW be secured, preferably bysupplemental O2 required that their AW be secured, preferably by endotraqueal intubation.endotraqueal intubation. Guidelines:Guidelines: Hypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaOHypotension (SBP < 90 mmHg) or hypoxia (apnea, cyanosis or SaO22 < 90%) must be avoided and scrupulously avoided, if possible, or< 90%) must be avoided and scrupulously avoided, if possible, or corrected immediately in severe TBI patients.corrected immediately in severe TBI patients. Options:Options: The MAP should be maintained above 90 mmHg through theThe MAP should be maintained above 90 mmHg through the infusion of fluids throughout the patient’s course to attempt toinfusion of fluids throughout the patient’s course to attempt to maintain CPP > 70 mmHg. Patients with GCS < 9 who are unable tomaintain CPP > 70 mmHg. Patients with GCS < 9 who are unable to maintain their airway or who remain hypoxemic despitemaintain their airway or who remain hypoxemic despite supplemental O2 required that their AW be secured, preferably bysupplemental O2 required that their AW be secured, preferably by endotraqueal intubation.endotraqueal intubation.
  12. 12. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD  Differences in the incidence of hypoxia and hypotension in the Emergency Room, Differences in the incidence of hypoxia and hypotension in the Emergency Room,  between 1987 and 1997 (p 0.01).between 1987 and 1997 (p 0.01). 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Hypoxia Hypotension 1987 1997 Incidence of hypoxia and hypotensionIncidence of hypoxia and hypotension
  13. 13. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD GOS according to the presence ofGOS according to the presence of hypotensionhypotension 0% 10% 20% 30% 40% 50% 60% 70% 80% Without hypotension Inicial hypotension (30) Late hypotensión (117) Both(39) GOS 4-5 GOS 3 GOS 1-2 Modified from Chesnut R. Acta Neurochir SupplModified from Chesnut R. Acta Neurochir Suppl 1993;59:121.1993;59:121.
  14. 14. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD 0% 10% 20% 30% 40% 50% 60% 70% 80% GOS 4-5 GOS 2-3 GOS 1 No hypotension Inicial hypotension inicial Initial Hypotension and GOSInitial Hypotension and GOS p 0.008 p 0.29 p 0.01
  15. 15. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Total (699) Inicial Hypoxia (78) Late hypoxia (161) GOS 4-5 GOS 2-3 GOS 1 GOS according to the presence ofGOS according to the presence of hypoxiahypoxia Modified from Chesnut R. J Trauma 1993;34:206Modified from Chesnut R. J Trauma 1993;34:206
  16. 16. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Indications for intracranialIndications for intracranial pressure monitoringpressure monitoring Guidelines:Guidelines: Comatose head injury patients (GCS 3-8) with abnormal CT scans shouldComatose head injury patients (GCS 3-8) with abnormal CT scans should undergo ICP monitoring. Comatose patients with normal CT scans have aundergo ICP monitoring. Comatose patients with normal CT scans have a much lower incidence of intracranial hypertension unless they have two ormuch lower incidence of intracranial hypertension unless they have two or more of the following features at admission: age over 40, unilateral ormore of the following features at admission: age over 40, unilateral or bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg.bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg. ICP monitoring in patients with a normalICP monitoring in patients with a normal CT scan with two or more of these risk factors is suggested as a guideline.CT scan with two or more of these risk factors is suggested as a guideline. Routine ICP monitoring is not indicated in patients with mild or moderateRoutine ICP monitoring is not indicated in patients with mild or moderate head injury. However, it may be undertaken in certain conscious patientshead injury. However, it may be undertaken in certain conscious patients with traumatic mass lesions at the discretion of the treating physician.with traumatic mass lesions at the discretion of the treating physician. Guidelines:Guidelines: Comatose head injury patients (GCS 3-8) with abnormal CT scans shouldComatose head injury patients (GCS 3-8) with abnormal CT scans should undergo ICP monitoring. Comatose patients with normal CT scans have aundergo ICP monitoring. Comatose patients with normal CT scans have a much lower incidence of intracranial hypertension unless they have two ormuch lower incidence of intracranial hypertension unless they have two or more of the following features at admission: age over 40, unilateral ormore of the following features at admission: age over 40, unilateral or bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg.bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg. ICP monitoring in patients with a normalICP monitoring in patients with a normal CT scan with two or more of these risk factors is suggested as a guideline.CT scan with two or more of these risk factors is suggested as a guideline. Routine ICP monitoring is not indicated in patients with mild or moderateRoutine ICP monitoring is not indicated in patients with mild or moderate head injury. However, it may be undertaken in certain conscious patientshead injury. However, it may be undertaken in certain conscious patients with traumatic mass lesions at the discretion of the treating physician.with traumatic mass lesions at the discretion of the treating physician.
  17. 17. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Intracranial pressure monitoringIntracranial pressure monitoring 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1987 1997 Differences in the use of intracranial pressure monitoring devicesDifferences in the use of intracranial pressure monitoring devices between 1987 and 1997.between 1987 and 1997.
  18. 18. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Intracranial pressureIntracranial pressure treatment thresholdtreatment threshold GuidelinesGuidelines An absolute ICP threshold that is uniformly applicable isAn absolute ICP threshold that is uniformly applicable is unlikely to exist. Current data, however, support 20-25unlikely to exist. Current data, however, support 20-25 mm Hg as an upper threshold above which treatment tomm Hg as an upper threshold above which treatment to lower ICP should generally be initiated.lower ICP should generally be initiated. OptionsOptions Interpretation and treatment of ICP based on anyInterpretation and treatment of ICP based on any threshold should be corroborated by frequent clinicalthreshold should be corroborated by frequent clinical examination and CPP data.examination and CPP data. GuidelinesGuidelines An absolute ICP threshold that is uniformly applicable isAn absolute ICP threshold that is uniformly applicable is unlikely to exist. Current data, however, support 20-25unlikely to exist. Current data, however, support 20-25 mm Hg as an upper threshold above which treatment tomm Hg as an upper threshold above which treatment to lower ICP should generally be initiated.lower ICP should generally be initiated. OptionsOptions Interpretation and treatment of ICP based on anyInterpretation and treatment of ICP based on any threshold should be corroborated by frequent clinicalthreshold should be corroborated by frequent clinical examination and CPP data.examination and CPP data.
  19. 19. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Recommendations for intracranialRecommendations for intracranial pressure monitoring technologypressure monitoring technology In patients who require ICP monitoring, a ventricular catheterIn patients who require ICP monitoring, a ventricular catheter connected to an external strain gauge transducer or catheter tipconnected to an external strain gauge transducer or catheter tip pressure transducer device is the most accurate reliable method ofpressure transducer device is the most accurate reliable method of monitoring ICP and enables therapeutic CSF drainage. Clinicallymonitoring ICP and enables therapeutic CSF drainage. Clinically significant infections or hemorrhage associated with ICP devicessignificant infections or hemorrhage associated with ICP devices causing patient morbidity are rare and should not deter the decisioncausing patient morbidity are rare and should not deter the decision to monitor ICP. Parenchymal catheter tip pressure transducerto monitor ICP. Parenchymal catheter tip pressure transducer devices measure ICP similar to ventricular ICP pressure but havedevices measure ICP similar to ventricular ICP pressure but have the potential for significant measurement differences and drift due tothe potential for significant measurement differences and drift due to the inability to recalibrate. These devices are advantageous whenthe inability to recalibrate. These devices are advantageous when ventricular ICP is not obtained or if there is obstruction in the fluidventricular ICP is not obtained or if there is obstruction in the fluid couple. Subarachnoid or subdural fluid coupled devices and epiduralcouple. Subarachnoid or subdural fluid coupled devices and epidural ICP devices are currently less accurateICP devices are currently less accurate In patients who require ICP monitoring, a ventricular catheterIn patients who require ICP monitoring, a ventricular catheter connected to an external strain gauge transducer or catheter tipconnected to an external strain gauge transducer or catheter tip pressure transducer device is the most accurate reliable method ofpressure transducer device is the most accurate reliable method of monitoring ICP and enables therapeutic CSF drainage. Clinicallymonitoring ICP and enables therapeutic CSF drainage. Clinically significant infections or hemorrhage associated with ICP devicessignificant infections or hemorrhage associated with ICP devices causing patient morbidity are rare and should not deter the decisioncausing patient morbidity are rare and should not deter the decision to monitor ICP. Parenchymal catheter tip pressure transducerto monitor ICP. Parenchymal catheter tip pressure transducer devices measure ICP similar to ventricular ICP pressure but havedevices measure ICP similar to ventricular ICP pressure but have the potential for significant measurement differences and drift due tothe potential for significant measurement differences and drift due to the inability to recalibrate. These devices are advantageous whenthe inability to recalibrate. These devices are advantageous when ventricular ICP is not obtained or if there is obstruction in the fluidventricular ICP is not obtained or if there is obstruction in the fluid couple. Subarachnoid or subdural fluid coupled devices and epiduralcouple. Subarachnoid or subdural fluid coupled devices and epidural ICP devices are currently less accurateICP devices are currently less accurate
  20. 20. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Guidelines for cerebralGuidelines for cerebral perfusion pressureperfusion pressure Option:Option: Maintenance of a CPP above 70 mm Hg is a therapeuticMaintenance of a CPP above 70 mm Hg is a therapeutic option that may be associated with a substantial reductionoption that may be associated with a substantial reduction in mortality and improvement in quality of survival and isin mortality and improvement in quality of survival and is likely to enhance perfusion to ischemic regions of thelikely to enhance perfusion to ischemic regions of the brain following severe TBI. No study has demonstratedbrain following severe TBI. No study has demonstrated that the incidence of intracranial hypertension, morbidity,that the incidence of intracranial hypertension, morbidity, or mortality is increased by the active maintenance ofor mortality is increased by the active maintenance of CPP above 70 mm Hg, even if this means normalizing theCPP above 70 mm Hg, even if this means normalizing the intravascular volume or inducing systemic hypertensionintravascular volume or inducing systemic hypertension Option:Option: Maintenance of a CPP above 70 mm Hg is a therapeuticMaintenance of a CPP above 70 mm Hg is a therapeutic option that may be associated with a substantial reductionoption that may be associated with a substantial reduction in mortality and improvement in quality of survival and isin mortality and improvement in quality of survival and is likely to enhance perfusion to ischemic regions of thelikely to enhance perfusion to ischemic regions of the brain following severe TBI. No study has demonstratedbrain following severe TBI. No study has demonstrated that the incidence of intracranial hypertension, morbidity,that the incidence of intracranial hypertension, morbidity, or mortality is increased by the active maintenance ofor mortality is increased by the active maintenance of CPP above 70 mm Hg, even if this means normalizing theCPP above 70 mm Hg, even if this means normalizing the intravascular volume or inducing systemic hypertensionintravascular volume or inducing systemic hypertension
  21. 21. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD CPP and outcomeCPP and outcome 66 68 70 72 74 76 78 80 82 84 GOS 2-5 GOS 1-3 GOS 4-5 GOS 1 GOS 2 GOS 3 GOS 5 Mean CPP Statistical differences (two tails) for CPP were found for: GOS 2 - 5 against GOS 1 (pStatistical differences (two tails) for CPP were found for: GOS 2 - 5 against GOS 1 (p < 0.01), GOS 4 - 5 against GOS 1 - 3 (p < 0.01), GOS 5 against GOS 3 (p 0.02), GOS 5< 0.01), GOS 4 - 5 against GOS 1 - 3 (p < 0.01), GOS 5 against GOS 3 (p 0.02), GOS 5 against GOS 2 (p 0.01) and GOS 5 against GOS 1 (p < 0.01).against GOS 2 (p 0.01) and GOS 5 against GOS 1 (p < 0.01).
  22. 22. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Effectiveness of raising CPP withEffectiveness of raising CPP with dopaminedopamine -10 -5 0 5 10 15 20 25 30 35 MAP ICP CPP PtiO2 SjO2 CPP > 60 CPP < 40 * * p < 0.05 * * * * * Modified from Unterberg AW, J Trauma 1997;42Supp:S33Modified from Unterberg AW, J Trauma 1997;42Supp:S33
  23. 23. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Effectiveness of head positionEffectiveness of head position 0 1 2 3 4 5 6 7 MAP ICP CPP PtiO2 SjO2 0º head * * p < 0.05 * Modified from Unterberg AW, J Trauma 1997;42Supp:S33Modified from Unterberg AW, J Trauma 1997;42Supp:S33
  24. 24. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD HyperventilationHyperventilation StandardStandard In the absence of increased ICP chronic prolonged HV therapy (PaCOIn the absence of increased ICP chronic prolonged HV therapy (PaCO22 << 25 mmHg) should be avoided after TBI.25 mmHg) should be avoided after TBI. GuidelinesGuidelines The use of prophylactic HV (PaCOThe use of prophylactic HV (PaCO22 << 30 mmHg) during the first 24 hs30 mmHg) during the first 24 hs after severe TBI should be avoided because it can compromise cerebralafter severe TBI should be avoided because it can compromise cerebral perfusion during a time when CBF is reduced.perfusion during a time when CBF is reduced. OptionsOptions HV may be necessary for brief periods when there is acute neurologicalHV may be necessary for brief periods when there is acute neurological deterioration or for longer periods if there is refractory intracranialdeterioration or for longer periods if there is refractory intracranial hypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help tohypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help to identify cerebral ischemia if HV is necessary.identify cerebral ischemia if HV is necessary. StandardStandard In the absence of increased ICP chronic prolonged HV therapy (PaCOIn the absence of increased ICP chronic prolonged HV therapy (PaCO22 << 25 mmHg) should be avoided after TBI.25 mmHg) should be avoided after TBI. GuidelinesGuidelines The use of prophylactic HV (PaCOThe use of prophylactic HV (PaCO22 << 30 mmHg) during the first 24 hs30 mmHg) during the first 24 hs after severe TBI should be avoided because it can compromise cerebralafter severe TBI should be avoided because it can compromise cerebral perfusion during a time when CBF is reduced.perfusion during a time when CBF is reduced. OptionsOptions HV may be necessary for brief periods when there is acute neurologicalHV may be necessary for brief periods when there is acute neurological deterioration or for longer periods if there is refractory intracranialdeterioration or for longer periods if there is refractory intracranial hypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help tohypertension. SjO2, AJDO2, PtiO2 and CBF monitoring may help to identify cerebral ischemia if HV is necessary.identify cerebral ischemia if HV is necessary.
  25. 25. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD The effect of hyperventilationThe effect of hyperventilation -25 -20 -15 -10 -5 0 5 10 15 20 MAP ICP CPP ETCO2 PtiO2 SjO2 Hyperventilation * * p < 0.05 * * * * Modified from Unterberg AW, J Trauma 1997;42Supp:S33Modified from Unterberg AW, J Trauma 1997;42Supp:S33
  26. 26. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Use of MannitolUse of Mannitol GuidelinesGuidelines Mannitol is effective for control of raised ICP after severe TBI. EffectiveMannitol is effective for control of raised ICP after severe TBI. Effective doses range from 0.25 to 1 g/kg/body weight.doses range from 0.25 to 1 g/kg/body weight. OptionsOptions Indications to it use prior to ICP monitoring are signs of transtentorialIndications to it use prior to ICP monitoring are signs of transtentorial herniation or neurological worsening not attributable to extracranialherniation or neurological worsening not attributable to extracranial explanations. Hypovolemia should be avoided by fluid replacement.explanations. Hypovolemia should be avoided by fluid replacement. Serum osmolarity should be kept below 300 mOsm because of concern forSerum osmolarity should be kept below 300 mOsm because of concern for renal failure.renal failure. Euvolemia should be maintained by adequate fluid replacement. A FoleyEuvolemia should be maintained by adequate fluid replacement. A Foley catheter is essential in these patients.catheter is essential in these patients. Intermittent boluses may be more effective than continuous infusion.Intermittent boluses may be more effective than continuous infusion. GuidelinesGuidelines Mannitol is effective for control of raised ICP after severe TBI. EffectiveMannitol is effective for control of raised ICP after severe TBI. Effective doses range from 0.25 to 1 g/kg/body weight.doses range from 0.25 to 1 g/kg/body weight. OptionsOptions Indications to it use prior to ICP monitoring are signs of transtentorialIndications to it use prior to ICP monitoring are signs of transtentorial herniation or neurological worsening not attributable to extracranialherniation or neurological worsening not attributable to extracranial explanations. Hypovolemia should be avoided by fluid replacement.explanations. Hypovolemia should be avoided by fluid replacement. Serum osmolarity should be kept below 300 mOsm because of concern forSerum osmolarity should be kept below 300 mOsm because of concern for renal failure.renal failure. Euvolemia should be maintained by adequate fluid replacement. A FoleyEuvolemia should be maintained by adequate fluid replacement. A Foley catheter is essential in these patients.catheter is essential in these patients. Intermittent boluses may be more effective than continuous infusion.Intermittent boluses may be more effective than continuous infusion.
  27. 27. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Effectiveness of mannitol 0.5Effectiveness of mannitol 0.5 g/kg/bolus administrationg/kg/bolus administration -8 -6 -4 -2 0 2 4 6 8 10 12 MAP ICP CPP PtiO2 SjO2 ICP < 20 ICP > 20 Modified from Unterberg AW, J Trauma 1997;42Supp:S33Modified from Unterberg AW, J Trauma 1997;42Supp:S33 * p < 0.05 SjO2 basal 69%, Pti O2 basal 39 mmHg,SjO2 basal 69%, Pti O2 basal 39 mmHg, * *
  28. 28. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Use of barbiturates in the controlUse of barbiturates in the control of intracranial hypertensionof intracranial hypertension Guideline:Guideline: High-dose barbiturate therapy is efficacious inHigh-dose barbiturate therapy is efficacious in lowering ICP and decreasing mortality in the setting oflowering ICP and decreasing mortality in the setting of uncontrollable ICP refractory to all other conventionaluncontrollable ICP refractory to all other conventional medical and surgical ICP-lowering treatments, inmedical and surgical ICP-lowering treatments, in salvageable TBI patients. Utilization of barbiturates forsalvageable TBI patients. Utilization of barbiturates for the prophylactic treatment of ICP is not indicated.the prophylactic treatment of ICP is not indicated. Guideline:Guideline: High-dose barbiturate therapy is efficacious inHigh-dose barbiturate therapy is efficacious in lowering ICP and decreasing mortality in the setting oflowering ICP and decreasing mortality in the setting of uncontrollable ICP refractory to all other conventionaluncontrollable ICP refractory to all other conventional medical and surgical ICP-lowering treatments, inmedical and surgical ICP-lowering treatments, in salvageable TBI patients. Utilization of barbiturates forsalvageable TBI patients. Utilization of barbiturates for the prophylactic treatment of ICP is not indicated.the prophylactic treatment of ICP is not indicated.
  29. 29. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Role of steroidsRole of steroids Standard:Standard: The majority of available evidence indicates thatThe majority of available evidence indicates that steroids do not improve outcome or lower ICP insteroids do not improve outcome or lower ICP in severely head-injured patients. The routine use ofseverely head-injured patients. The routine use of steroids is not recommended for these purposes.steroids is not recommended for these purposes. Standard:Standard: The majority of available evidence indicates thatThe majority of available evidence indicates that steroids do not improve outcome or lower ICP insteroids do not improve outcome or lower ICP in severely head-injured patients. The routine use ofseverely head-injured patients. The routine use of steroids is not recommended for these purposes.steroids is not recommended for these purposes.
  30. 30. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Use of steroidsUse of steroids 0% 10% 20% 30% 40% 50% 60% 70% 80% 1987 1997 Differences in the use of steroids between 1987 and 1997. This difference wasDifferences in the use of steroids between 1987 and 1997. This difference was statistically significant (p > 0.0001) in terms of morbimortalitystatistically significant (p > 0.0001) in terms of morbimortality..
  31. 31. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD MonitoringMonitoring (49)(49) MonitoringMonitoring (49)(49) CPP > 70CPP > 70 (52)(52) CPP > 70CPP > 70 (52)(52) ICP > 20ICP > 20 YesYes Ventricular drainage (4)Ventricular drainage (4)Ventricular drainage (4)Ventricular drainage (4) Mannitol 0.5 g/kg/ boloMannitol 0.5 g/kg/ bolo (41)(41) Mannitol 0.5 g/kg/ boloMannitol 0.5 g/kg/ bolo (41)(41) PIC > 20PIC > 20 ICP > 20ICP > 20 PIC > 20PIC > 20 HV PCOHV PCO22 30 - 3530 - 35 (31)(31) HV PCOHV PCO22 30 - 3530 - 35 (31)(31) YesYes NoNo ConsidererConsiderer repeat CTrepeat CT ConsidererConsiderer repeat CTrepeat CT CautiousCautious treatmenttreatment withdrawalwithdrawal CautiousCautious treatmenttreatment withdrawalwithdrawal NoNo NoNoYesYes YesYes CPP ManagementCPP Management (22)(22) CPP ManagementCPP Management (22)(22) High dose barbiturates (4) High dose barbiturates (4) HV PCO2 < 30 TorrHV PCO2 < 30 Torr SjO2 Monitoring (5)SjO2 Monitoring (5) HV PCO2 < 30 TorrHV PCO2 < 30 Torr SjO2 Monitoring (5)SjO2 Monitoring (5)
  32. 32. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD NutritionNutrition Guidelines:Guidelines: Replace 140% of resting metabolism expenditure inReplace 140% of resting metabolism expenditure in nonparalyzed patients and 100% in paralized patientsnonparalyzed patients and 100% in paralized patients using enteral or parenteral formulas containing at leastusing enteral or parenteral formulas containing at least 15% of calories as protein by day 7 after injury.15% of calories as protein by day 7 after injury. Options:Options: The preferable option is use of jejunal feeding byThe preferable option is use of jejunal feeding by gastrojejunostomy due to ease of use and avoidance ofgastrojejunostomy due to ease of use and avoidance of gastric intolerance.gastric intolerance. Guidelines:Guidelines: Replace 140% of resting metabolism expenditure inReplace 140% of resting metabolism expenditure in nonparalyzed patients and 100% in paralized patientsnonparalyzed patients and 100% in paralized patients using enteral or parenteral formulas containing at leastusing enteral or parenteral formulas containing at least 15% of calories as protein by day 7 after injury.15% of calories as protein by day 7 after injury. Options:Options: The preferable option is use of jejunal feeding byThe preferable option is use of jejunal feeding by gastrojejunostomy due to ease of use and avoidance ofgastrojejunostomy due to ease of use and avoidance of gastric intolerance.gastric intolerance.
  33. 33. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD Role of antiseizure prophylaxisRole of antiseizure prophylaxis following head injuryfollowing head injury Standard:Standard: Prophylactic use of phenytoin, carbamazepine, phenobarbital orProphylactic use of phenytoin, carbamazepine, phenobarbital or valproate, is not recommended for preventing latevalproate, is not recommended for preventing late posttraumatic seizures.posttraumatic seizures. Options:Options: Anticonvulsivants may be used to prevent early PTS in patientsAnticonvulsivants may be used to prevent early PTS in patients at risk. This prevention does not indicate an improvement inat risk. This prevention does not indicate an improvement in outcome.outcome. Standard:Standard: Prophylactic use of phenytoin, carbamazepine, phenobarbital orProphylactic use of phenytoin, carbamazepine, phenobarbital or valproate, is not recommended for preventing latevalproate, is not recommended for preventing late posttraumatic seizures.posttraumatic seizures. Options:Options: Anticonvulsivants may be used to prevent early PTS in patientsAnticonvulsivants may be used to prevent early PTS in patients at risk. This prevention does not indicate an improvement inat risk. This prevention does not indicate an improvement in outcome.outcome.
  34. 34. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD 0% 20% 40% 60% 80% 1987 1990 1994 1997 1999 Hospital Fernández, Buenos Aires, Severe Head Injury mortality ratesHospital Fernández, Buenos Aires, Severe Head Injury mortality rates from 1987 to 1999from 1987 to 1999
  35. 35. IJP´01IJP´01 Ignacio J. Previgliano, MDIgnacio J. Previgliano, MD
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