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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

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

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