Scarecrow Nti


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Scarecrow Nti

  1. 1. Traumatic Brain Injury Management- What Really Happened to the Scarecrow Glenn Carlson APRN, MSN, CCRN Critical Care Clinical Nurse Specialist Bronson Methodist Hospital Kalamazoo, MI
  2. 2. TBI case review I have no conflict of interest with any of the information presented in this review. Glenn Carlson APRN, MSN, CCRN I am on the AACN speaker’s bureau
  3. 3. Dorothy and tornado http://www. youtube .com/watch?v=5xNA8seaqGQ&feature=related
  4. 4. Dorothy meets scarecrow http://www. youtube .com/watch?v= wKrJoih _ uCQ
  5. 5. Case 1
  6. 6. Case 2
  7. 7. Egypt- Lessons from war <ul><li>A doctor would first carefully lift larger broken pieces of skull off of the brain, and then any small fragments would be brushed away and discarded.  The larger pieces would be carefully replaced onto the brain, and a disinfectant made of warm wine and rose oil (they didn’t know it killed germs, because they did not yet understand the germ theory) was put against the outer membrane of the brain.  At last, the patient’s head would be wrapped in bandages; eventually, many would heal.  This, along with twenty-six other techniques for treating head injuries is described in the Smith’s Papyrus. </li></ul>
  8. 8. FYI- part of series on <ul><li>The Papyrus was on display at the Met from September 13, 2005, through January 15, 2006. </li></ul>
  9. 9. Trephining <ul><li>Used to relieve pressure </li></ul><ul><li>Used to let out demons </li></ul>
  10. 10. Australian doctor uses household drill to save boy- May 20, 2009 MELBOURNE, Australia – A doctor in rural Australia used a handyman's power drill to bore a hole into the skull of a boy with a severe head injury, saving his life. Nicholas Rossi fell off his bike on Friday in the small Victoria state city of Maryborough, hitting his head on the pavement, his father, Michael, said Wednesday. By the time Rossi got to the hospital, he was slipping in and out of consciousness. The doctor on duty, Rob Carson, quickly recognized the boy was experiencing potentially fatal bleeding on the brain and knew he had only minutes to make a hole in the boy's skull to relieve the pressure. But the small hospital was not equipped with neurological drills — so Carson sent for a household drill from the maintenance room. &quot;Dr. Carson came over to us and said, 'I am going to have to drill into (Nicholas) to relieve the pressure on the brain — we've got one shot at this and one shot only,'&quot; Michael Rossi told The Australian newspaper. Carson called a neurosurgeon in the state capital of Melbourne for help, who talked Carson through the procedure — which he had never before attempted — by telling him where to aim the drill and how deep to go. &quot;All of a sudden the emergency ward was turned into an operating theater,&quot; Michael Rossi told Fairfax Radio on Wednesday. &quot;We didn't see anything, but we heard the noises, heard the drill. It was just one of those surreal experiences.&quot;
  11. 11. Brain Injury management <ul><li>Hyperventilation </li></ul><ul><li>Steroids </li></ul><ul><li>Dehydration </li></ul><ul><li>Craniectomy </li></ul>: Chest. 2005 May;127(5):1812-27 . Stocchetti N , Maas AI , Chieregato A , van der Plas AA . Primer on medical management of severe brain injury Jean-Louis Vincent, MD, PhD, FCCM; Jacques Berré, MD Crit Care Med 2005; 33:1392–1399
  12. 12. Hyperventilation- goal is to keep PCO2 at 35 <ul><li>Theory is decreased CO2 causes vasoconstriction and decreased ICP </li></ul><ul><ul><li>Rebound intracranial hypertension may occur </li></ul></ul><ul><ul><li>Vasoconstriction decreases flow in the TBI patient who already may have impaired CBF by up to 50% r/t the TBI. </li></ul></ul><ul><ul><li>May promote cellular anaerobic metabolism and a shift in the oxyhemoglobin curve- less oxygen release from the blood (theory) </li></ul></ul><ul><li>Moderate CO2 reduction for short periods may be beneficial (28-35, never less than 25) </li></ul><ul><li>Long periods of CO2 reduction has been shown to increase mortality in the TBI patient </li></ul>Critical Care Medicine: Volume 25(8) August 1997 pp 1402-1409 Effect of hyperventilation on regional cerebral blood flow in head-injured children Skippen, Peter FANZCA; Seear, Michael FRCP; Poskitt, Ken FRCP; Kestle, John FRCSC; Cochrane, Doug FRCSC; Annich, Gail FRCP; Handel, Jeffrey MRCP
  13. 13. Steroids- Crash Trial <ul><li>Although beneficial in reducing edema associated with brain tumor, not recommended for brain injury. No change in outcome and increased potential for infection. Crash trial (Corticosteroid randomization after significant head injury) reported in Lancet 2004. Patient who received steroids had a greater 2 week mortality. </li></ul>
  14. 14. Dehydration <ul><li>No longer drying out patients </li></ul><ul><li>Maintain euvolemic state. Arterial hypotension in trauma most of the time indicates hypovolemia. </li></ul><ul><li>Volume is indicated when cerebral blood flow (oxygenation) is low and CPP low (less than 60) </li></ul><ul><li>Too much fluid can cause ARDS </li></ul>
  15. 15. Craniectomy <ul><li>Early (within 24 hours) versus late within 48 hours), upper ICP limit. Early has been show to have some benefit especially for patients with ICP < 40mmHg </li></ul><ul><li>Unilateral frontotemporoparietal bone flap vs. temporoparietal bone flap. Article in Neurotrauma suggests that unilateral frontotemporalparietal bone flap provides better outcome in patients with refractory intracranial hypertension </li></ul>
  16. 16. <ul><li>Initial gift of $350,000 with additional $350,000 in 2004 was funded by a former patient’s family (Williams). </li></ul><ul><li>Support was used to bring the BTF (Brain Trauma Foundation) Guidelines and Technology used to manage TBI patients to twenty trauma centers in US. Bronson applied and was selected as one of the twenty trauma centers in 2004 to begin the initiative in 2005. </li></ul>
  17. 17. What is it <ul><li>Analysis of AANS (American Association of Neurologic Surgeons) TBI guidelines </li></ul><ul><li>– Avoid hypotension/hypoxia </li></ul><ul><li>– Maintain MAP > 90 mm Hg </li></ul><ul><li>– Maintain CPP > 70 mm Hg </li></ul><ul><li>– Treat ICP > 20 mm Hg </li></ul><ul><li>– Avoid hyperventilation in severe TBI unless cerebral oxygenation is monitored </li></ul><ul><li>– Use intermittent mannitol with replacement of fluids to maintain euvolemia </li></ul><ul><li>– Use barbiturates for uncontrollable ICP </li></ul><ul><li>– Use craniectomy for uncontrollable ICP </li></ul><ul><li>– Establish a critical pathway/algorithm </li></ul><ul><li>– Increase MAP with albumin and vasopressors </li></ul><ul><li>– Decrease environmental stimulation </li></ul><ul><li>– Use sedation and analgesia in continuous modes </li></ul><ul><li>– Treat fever aggressively </li></ul><ul><li>– Develop targeted therapy algorithms for specific clinical situations </li></ul><ul><li>– Incorporate a weaning algorithm </li></ul>
  18. 18. Brain monitoring early
  19. 19. Multimodal monitoring <ul><li>Cerebral oxygenation + ICP measurement + CSF drainage </li></ul><ul><ul><li>Via one access device or two </li></ul></ul><ul><li>SJO2 </li></ul>
  20. 20. Cerebral oxygenation via Licox
  21. 23. July TBI case review Case review
  22. 24. July TBI case review <ul><li>Teenage male passenger involved in high energy car versus train. </li></ul><ul><li>Left subdural hematoma (4mm) with 7 mm midline shift </li></ul><ul><li>C4 endplate (VB compression) fx- Aspen </li></ul><ul><li>Left pulmonary contusion with pneumothorax </li></ul><ul><li>Grade I liver laceration </li></ul><ul><li>Left humerous midshaft fx ORIF </li></ul><ul><li>Multiple scalp laceration and an avulsed chin, multiple other laceration and a thumb tendon tear </li></ul>
  23. 25. Continued review <ul><li>Patient admitted to SICU around 10:00 am. Lacerations to chin, head, elbow, thumb repaired. Awaiting Dr. England to come from the OR. Pupillometer in ED Cv of 1.28/1.36 (r/l) </li></ul><ul><li>LiCox place at 15:54 (about 10 hours after arrival) </li></ul><ul><li>Opening Pbto2 of 6.2, ICP 20, CPP 59, CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac) </li></ul><ul><li>At 19:00 PbTO2 remains less than 15, CPP 55, ICP 15, CVP 5 despite 500 cc albumin and 125 ug/min Neo </li></ul>
  24. 26. Continue Day 1 <ul><li>2 units of blood (HCT 32.7) ordered and PbtO2 responds t0 26.8 by 20:00 before 1 st unit completed, CVP 8, CPP 82. ICP 14. Neo at 135 ug/min </li></ul><ul><li>By the time the second unit of blood is infusing- 21:00 the PbtO2 is now 40, Neo down to 125 ug/min, CPP 79, ICP 8, CVP 8 </li></ul><ul><li>End tidal CO2 37-41, actually increased CO2 to increase PbtO2 at 19:00 and ICP 13 to 15. </li></ul><ul><li>BIS mostly in 50-60 </li></ul>
  25. 27. Continued Day 1 <ul><li>Coughing fit at 22:00 caused temporary elevation in ICP and PbtO2 to decrease to 11. Propofol increased, 100% oxygen, morphine bolus (patient moving all extremities at this time). </li></ul><ul><li>By 23:00 and draining 10 cc CSF- PbtO2 23, ICP down from 35 to 13. During this time patient ETCO2 46-51 (?bronchospasm) </li></ul><ul><li>First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements </li></ul>
  26. 28. Day 2 <ul><li>PbtO2 14 for 4 minutes when ICP >23, CSF drained, 100% oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100% oxygen flush) </li></ul><ul><li>CSF drainage worked well to keep ICP < 20. </li></ul><ul><li>Oxygen weaned to 50% by 10:00 and Neo to 80 ug/min </li></ul><ul><li>1L albumin additional fluid for Day 2 (However remember no Mannitol given as CSF drainage worked well to decrease ICP for 1 st 2 days. </li></ul>
  27. 29. Day 3 <ul><li>40% oxygen, Neo at 65ug/min, placed on sport bed </li></ul><ul><li>Additional 750 of albumin </li></ul><ul><li>PbtO2 mid 20s and 30s, gradual increasing EtCO2 with minimal effect on ICP. When ICP increased, CSF drained and an occasional propofol bolus. </li></ul>
  28. 30. Day 4 <ul><li>PbtO2 without any big drops, ICP elevations for total of 90 minutes throughout day, did get Mannitol x 1 and CSF drainage done. When PbtO2 drifted down, blood administered and remained in the 30s </li></ul>
  29. 31. Day 5 <ul><li>LiCox/Ventric discontinued. Patient attempting to open eyes. Neuro status waxing and waning. </li></ul><ul><li>Morphine and Ativan prematurely discontinued and restarted Day 5 night. </li></ul>
  30. 32. Rest of stay <ul><li>Extubated on Day 9 </li></ul><ul><li>BVH on Day 16 </li></ul><ul><li>Discharged to home from BVH after 9 days with remarkable improvement </li></ul><ul><ul><li>Independent ADLs </li></ul></ul><ul><ul><li>Continent </li></ul></ul><ul><ul><li>Memory improving </li></ul></ul><ul><ul><li>Walking 200 feet without assistance </li></ul></ul><ul><ul><li>Amnesia lessening </li></ul></ul><ul><ul><li>Problem solving improving although abstract thoughts and complex math remains difficult. </li></ul></ul><ul><ul><li>Socially interactive </li></ul></ul>
  31. 33. Case 1
  32. 34. Case 1- video play
  33. 35. Case 2
  34. 36. Case 2 More Pics
  35. 37. Case 2 Videos
  36. 38. Lessons learned <ul><li>It does work- grave prognosis to survival and continued progress towards independence </li></ul><ul><li>Fluid required despite not using mannitol- not just a brain injury </li></ul><ul><ul><li>Think scalp laceration blood loss </li></ul></ul><ul><ul><li>Other injury blood loss </li></ul></ul><ul><ul><li>Lactate is your friend </li></ul></ul><ul><ul><li>If Hct > 33 upon arrival, recheck in 4 hours after resus at Hct may have been hemoconcentrated. </li></ul></ul>
  37. 39. Net fluid by days- would need more if Mannitol used <ul><li>+900 </li></ul><ul><li>+1900 </li></ul><ul><li>+1500 </li></ul><ul><li>+2500 </li></ul><ul><li>+2200 </li></ul><ul><li>-200 </li></ul><ul><li>-1300 </li></ul><ul><li>-2800 </li></ul>
  38. 40. More lessons <ul><li>DO NOT STOP ANALGESIA OR ANXIOLYSIS, SLOW WEAN!!!! </li></ul><ul><li>CO2 can be your friend </li></ul><ul><li>VAP probability 32.7%- no VAP, HOB elevation and early rotational therapy vs. luck (called a tracheobronchitis). </li></ul>
  39. 41. ICP management- something new CRRT and Intracranial hypertension
  40. 42. Fletcher JJ, Bergman K, Feucht EC, Blostein P. Neurocrit Care. 2009 Mar 7. [Epub ahead of print]
  41. 44. Fletcher JJ, Bergman K, Feucht EC, Blostein P. Neurocrit Care. 2009 Mar 7. INTRODUCTION: Little is known about the effects of hemodialysis on the injured brain, however; concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy. Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety. Furthermore, exacerbations of cerebral edema have been reported. CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance. We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension. METHODS: A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma. He required significant volume resuscitation. Intensive care unit course was complicated by shock, acute respiratory distress syndrome, ventilator associated pneumonia, and development of intracranial hypertension (IH). Data were collected by retrospective chart review. RESULTS: Continuous hemofiltration was initiated for IH refractory to medical therapy. Within hours of initiation increase, ICP improved and normalized. Hemofiltration was safely discontinued after 48 h. Modified Rankin Score was 2 at 90 days. CONCLUSION: Though unproven, CRRT may be beneficial in patients with IH due to gentle removal of fluid, solutes, and inflammatory cytokines. Given the limited data on safety of CRRT in patients with ABI, we encourage further reports.
  42. 45. How does it work <ul><li>Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm </li></ul><ul><li>CRRT removes free water and may remove cardiac inhibitory factors </li></ul>
  43. 46. Indications
  44. 47. Indications
  45. 48. Indications
  46. 49. Indications
  47. 50. Indications
  48. 51. Indications
  49. 52. Indications
  50. 53. Indications
  51. 54. Resource for families
  52. 55. Questions