ICU Management of Traumatic Brain docs 2/News/Trauma presentations/Closed Head...Focal bruised areas...
Transcript of ICU Management of Traumatic Brain docs 2/News/Trauma presentations/Closed Head...Focal bruised areas...
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ICU Management of Traumatic Brain Injury
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ConcussionContusionff lDiffuse Axonal Inury
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Usually don’t require hospitalizationGrade 1‐Amnesia<30 min, no LOC
dGrade 2‐ LOC< 5 min, amnesia > 30 minGrade 3‐ LOC>5 min, amnesia =24 hrs
Second Injury Syndrome: Mortality 50‐100%
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ff fConcussion #2 – 1 month off if CT normal and only mild or moderate
d dConcussion #3‐ Season ending injury, do MRISame for Concussion #2 if severe
When will you see a concussion in the ICU?
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fFocal bruised areas of the brainAssociated edema
bl l blPossible enlargement (blossoming)
h ll hWhen will you see contusions in the ICU?
h llWhen will neurosurgery intervene?
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Grade I‐ coma 6‐ 24 hours, mild memory impairment, mild disability
d h lGrade II‐ coma >24 hours, long amnesia, behavior and cognitive deficits
d k hGrade III‐ coma weeks to months, posturing, cognitive, memory, speech, personality d fdeficits
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Minimal: GCS=15, no LOCMild: GCS= 14, may have brief LOC
d f lModerate: GCS= 9‐13 or LOC >5 min or focal neuro deficitSevere: GCS =5‐8Critical: GCS= 3‐4
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Minor Head Injury‐GCS= 14Elevate HOBNeurochecks q 1 or q 2 hrsNPO until alertNormal SalineMild analgesiagAntiemetic‐Tigan
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Moderate Head Injury GCS 9‐13Same as mild‐ to ICURepeat CT Head within 12‐24 hrs if pt does not return to GCS 14 or 15 within 12 hrs.
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Principles:
Cerebral Perfusion Pressure = MAP‐ICP
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Secondary Injury
l b l fIntracranial Pressure vs Cerebral Perfusion Pressure
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Normal CPP > 50 mm Hg
As long as CPP>60 mm Hg, higher CPP does b l dnot protect brain against elevated ICP.
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Normal Brain: 1400 mLCerebral Blood Volume: 150 mL
b l l l dCerebral Spinal Fluid: 150 mLClosed Skull
l d b d h h hPressure evenly distributed throughout the intracranial cavity
ll d h fMonroe‐Kellie doctrine‐ a change in one of the above necessitates a change in another.
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IndicationsNeurologic criteriaMultiple systems injured that may affect ICPTraumatic Intracranial Mass (EDH, SDH)Fulminant Liver Failure with Factor VII
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fInfectionHemorrhage
lf bMalfunction/obstructionMalposition
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Most accurateAllows fluid release to treat ICP elevationLower cost
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Camino or Honeywell/PhillipsMore expensiveMeasurement Drift
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Normal:A wave increases with arterial pulse
hVaries with respiration
h lPathologic waves:Lundberg A waves (plateau)Lundberg B waves (pressure pulses)Lundberg C waves
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Check output every hourCheck function every hour
flOverflowSet zero point
bl h blTroubleshoot problems
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Jugular Venous Oxygen MonitoringBrain Tissue Oxygen Tension Monitoring
d d f lBedside Monitoring of Regional CBF
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F ICP H d k CPP HFor ICP> 20 mm Hg, and keep CPP>70 mm Hg
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El t HOB dElevate HOB 30‐45 degreesNeck straight, no tight trach tapeSyst BP > 90 mm HgControl HypertensionypAvoid hypoxia‐ PaO2 <60 mm HgVentilate to normocarbiaLight sedationHypothermia controversialHypothermia‐ controversialCT Head for uncontrolled ICP
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H d i (f l hi d/ l i )Heavy sedation (fentanyl, morphine, and/or paralysis)Seizure ControlDrain 3‐5 cc CSF if Intraventricular catheter present3 5 pHyperventilate to PaCO2 30‐35 mm HgMannitol, keep serum Osmol. <320 Can add 23 5% Hypertonic Saline if Osmo allowsCan add 23.5% Hypertonic Saline if Osmo allowsHyperventilate to PaCO2 25‐30 mm HgCheck CT, EEG, proceed to next tier
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Hi h d b biHigh dose barbituratesHyperventilate to PaCO2 25‐30 mm HgHypothermia‐watch cardiac index, thrombocytopenia, yp , y p ,pancreatitis, avoid shiveringDecompressive surgeryLumbar DrainageLumbar DrainageHHH therapyIV Lidocaine‐ unprovenHi h f il i id if hi h PEEP i dHigh frequency ventilation‐ consider if high PEEP required
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More of these‐
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Means less of these!!!
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And More of these
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l f hMeans less of these!!!