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10 Things you Need to Know about TBI by Knight

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10 Things you Need to Know about TBI by Knight

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10 Things you Need to Know about TBI by Knight

  1. 1. Next Level Neuro Resus 26 June 2015 WilliamA Knight IV, MD, FACEP University of Cincinnati Traumatic Brain Injury – 10Things you Need to Know William.Knight@uc.edu @waknight4
  2. 2. Epidemiology:TBI in the US 50,000 Deaths 100,000 Hospitalizations 1,111,000 Emergency DepartmentVisits ?? Receiving Other Medical Care or No Care * Average annual numbers, 1995-2001 2004 CDC Report: TBI in the United States: ED Visits, Hospitalizations, and Deaths 1.5 – 2.0 million TBIs occur each year.*
  3. 3. Secondary Injury TBI Demyelination Mitochondrial Uncoupling Excitotoxic cascade Receptor activation Reduced GABA Inflammatory Cytokines Apoptosis Cerebral Edema Cytotoxic Edema Vasogenic Edema Pro Apoptotic cascade Free radicals & lipid peroxidation
  4. 4. WHATWE HAVE WHATWE NEED
  5. 5. Drug Reversal Method Evidenc e Cost Aspirin (ASA) • Platelets •Demsopressin (DDAVP) •rFVIIa (40mcg/kg) •weak •$1000 – 12 units •$1 / mcg Plavix (Clopidogrel) •Platelets •Demsopressin (DDAVP) •rFVIIa (40mcg/kg) • terrible •$1000 – 12 units •$1 / mcg Warfarin (Coumadin) •Vit K •FFP (250 cc / bag) •PCC •Cryoprecipitate •rFVIIa (40mcg/kg) • good •$10 / 10mg •$60 / bag •$5000 / dose •$1200 / 20 bags •$1 / mcg TSOACs •PCC (depends) •Antidotes •Weak •??? •$5000 / dose •??? Heparin •Protamine •solid NSAIDS •Platelets •DDAVP •garbage •$1000 – 12 units
  6. 6. NEJM 2000
  7. 7. Generalized spike/wave status
  8. 8. Narayan et al, J Nsurg 1981
  9. 9. 0% 25% 50% 75% 100% 3 4 5 6 7 8 GR MD SD Veg Dead Marshall et al, J Nsurg 1991
  10. 10.  DECRA ProTECT  Disease definition  Can what we see contributing to poor or good outcome be as wrong as these trials suggest or do we need to define the disease and patients better?  Multicenter RCTs can be successfully performed
  11. 11. Adeoye O & Shutter L. Neurotrauma & Critical Care of the Brain. JalloJ, ed. Thieme; 2009. CPP?
  12. 12.  Target normal physiologic goals  Research  We know how to study ▪ Do we know what to study?  Early aggressive care is the future  24 hours of resuscitation prior to prognosis
  13. 13. “It’s not an exceptional case. We just don’t know how many exceptions to the rule there are. So. I don’t believe in the rule anymore.” - Joseph Giacino, PhD http://nymag.com/scienceofus/2015/06/dylan-rizzo-coma.html

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