Review course 2014Dr.Anand.M.TiwariIDCC,F.N.B Critical care medicine
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
377 deaths daily.1356 –injury Yr 2012—1,38,245 deathYr 2013----1,37, 597
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
Prevention
Emergency Care
Critical Care
Brain specific therapy
MOI-
anand tiwari reveiw course 2014
1.Auto strikes tree.2.Head strikes windshield.3.Brain strikes inside of frontal skull.4.Brain rebounds and hits inside of occiput.
(Contracoup Injury)
Diffuse axonal injury 24% mortality
Focal lesion 39% mortality
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
HypoxiaHypotensionHypocapnia Remember H
EffectHypercapniaHyperthermiaHypoglycemiaHyperglycemiaHypernatremiaHyponatremiaHyperosmolarity infections
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
Review of 25 studiesHEMS showed survival benefit in someWhich component??Methodology?
Assessment.
Intervention * suboptimal interventions.
50% patient extracrainal injuries.
Cervical clearance.
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
GCS RTS APACHE Pupillary diameter and reactivity Age Hypotension CT scan features
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
GCS 13– mild
GCS 9-13- Moderate.
GCS < 8 - Severe
anand tiwari reveiw course 2014
Correction of reversible causes,Hypoxia,hypotension,c2h5oh intoxication
E V M*Sedationintubation
anand tiwari reveiw course 2014
Field cervical spine clearance isnot possible with altered LOC
1
2 3
4
1
2
3
4
anand tiwari reveiw course 2014
(a) a lateral view the base of the occiput to upper
border of first thoracic vertebrae,
(b) an anterior-posterior view C2 to T1 spinous processes. (c) an open-mouth odontoid view C1 lateral masses as well as the
whole odontoid process anand tiwari reveiw course 2014
2
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
Normal CT scan
Diffuse Axonal Injury
anand tiwari reveiw course 2014
Patient continues to remain unconscious .
Mild DAI Moderate DAI Severe DAI
coma between 6 and 24 hours
coma for more than 24 hours without presence of decerebrate posturing
coma for more than 24 hours and with presence of decerebrate posturing as a motor response on nociceptive stimulation.anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
Definite role in defining shear injuries and for prediction of prognosis
anand tiwari reveiw course 2014
FASTHUG
anand tiwari reveiw course 2014
Give your patient a fast hug (at least) once a day.Vincent JL.
Crystalloids NS,RL
Colloids
Blood transfusion TriggerUse of vasopressor-
Dopamine/noradrenaline
anand tiwari reveiw course 2014
Feeding ASAP ,<24 HRSHyper catabolicNG feed ? Orogastric tube Enteral
routeCan consider prokineticPEG long term
anand tiwari reveiw course 2014
Perel P, Yanagawa T, Bunn F, Roberts IG, Wentz R. Nutritional support for head-injured
patients. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001530. DOI: 10.1002/14651858.CD001530.pub2.
Early nutritional therapy in trauma: after A, B, C, D, E, the importance of the F (FEED) Alberto Bicudo-Salomão, ACBC-MTI; Renata Rodrigues de MouraII; José Eduardo de Aguilar-Nascimento, TCBC-MTIII
Rev. Col. Bras. Cir. vol.40 no.4 Rio de Janeiro July/Aug. 2013
anand tiwari reveiw course 2014
NeuroassesmentSedation vacation
Risk group- prolong sedation/extracranial injuries
Anticoagulant/LMWH___-????Look for –illeo femoralGraduated TED stockings/pneumatic
calf compressor unproven reasonable alternative
anand tiwari reveiw course 2014
Head in neutral positionVenous drainageNo compression of neck veins by
tube tie
anand tiwari reveiw course 2014
GCS charting frequentlyDaily fast hugHemodynamic monitoringFluid balanceBBB careBrain specific monitoringNeurosurgical consultation as
needed
anand tiwari reveiw course 2014
BATTLE’S SIGN RACCOON EYES
anand tiwari reveiw course 2014
CSF Fistule : Rhinorrhoea / Otorrhoea
Risk of meningitis*
** Early Rx -- Carbapenem .
**Topical (intrathecal or intraventricular) therapy colistin (off label ) for A.baumanii meningitis.
Craniofacial trauma
CSF leak new onset fever
Median time presentation 12 days.
suspicion of gram negative meningitis
124 Case Report- A.baumanii meningitis
Know your ICU/organism prevalent and resistant pattern
Preemptive antibiotics ????Stratify risk factorsSite specific ,bbb penetrationOther factors
anand tiwari reveiw course 2014
Which mode?No permissive hypercapniaPeep ???
Weaning—Off ventilator does not mean
extubation
anand tiwari reveiw course 2014
Hyperventilation
Euglycemia =<150mg% favarouable
Na Disturbances- SIADH CSW syndrome Diabetes insipidusCore temp-- Normal
anand tiwari reveiw course 2014
CPP= MAP-ICP
70……BTF initial adoption*aggressive fluid/vasopressor..pulmonary complications
…60 anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
ICP MONITORING
Ocular ultrasound
Jugular bulb oximetry
Transcranial Doppler
Cerebral micro dialysis
Intracranial pressure monitoring 1.comatose patients with- Glasgow Coma Scale (GCS) 3-8 with abnormal
computed tomography (CT) scans
2.Normal CT scans with two or more 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.
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
] The optic nerve sheath diameter measurement was found to be well-correlated with the values of ICP and its value significantly increased to 7.0 ± 0.58 mm, when ICP rose in value to >20 mm Hg
EEG-SEP monitoring reflects to remaining metabolic activity of brain parenchyma.
EEG recordings usually get suppressed and difficult to interpret during deep sedation.
anand tiwari reveiw course 2014
Surgical decompressionCSF drainageDecompressive craniectomyOsmotherapyHyperventilationHypotheramiaBarbiturate comaSteroidsCerebral vasospasm-nimodipineSeizure prophylaxis
anand tiwari reveiw course 2014
Fig. 7. The Columbia stepwise protocol for ICP
anand tiwari reveiw course 2014
MANNITOL
Single bolus & prolonged
Improves rheological value of RBCs & CPP
Rebound phenomenon.
Currently preferred
HYPERTONIC SALINE
Studies with single bolus & infusion …but limitations
Osmotic mobility decreases leukocyte adhesion.
Central pontine myelinosis (if hypoNa+)
??
anand tiwari reveiw course 2014
?? Mannitol Vs H.S.?? Optimal conc. Of H.S.?? Outcomes of prolonged H.S. in raised ICP
MANNITOL 20%
.25-1 gm/kg @ prn Rheological effects Adverse effects
HTS 1.7%--29.2%
5% 2ml/kg 4-6 hrly. Serum osmolarity*-
320
Na*..155 meq/l
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
In this prospective evaluation of early PTS prophylaxis,
LEV did not outperform PHE.
Cost and need for serum monitoring should be considered in guiding the choice of prophylactic agent.
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
Discuss BTF guideline for surgery
An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patient's Glasgow Coma Scale (GCS) score.
An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning
close neurological observation in a neurosurgical center.
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
Discuss BTF guideline for evacuation??
An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a MLS greater than 5 mm on CT scan should be surgically evacuated, regardless of the patient's GCS score.
All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring.
A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and MLS less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg
anand tiwari reveiw course 2014
Barbiturate coma BIS-5-20 EEG-Burst suppression.
Decompression craniotomy.Hypothermia 35*CSF drainageReconsider treatment.
anand tiwari reveiw course 2014
Refractory casesDecrease CMRO2/Problem hypotension remember pearl harbor incidentAim till burst suppression on EEGGradual taper –delayed
awakening ,predispose patient to nosocomial infection
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
Awaits RESCUEicp results
reduces all cause mortality***
May be beneficial in improving neurological outcomesif cooling maintained for 48 hrs.
anand tiwari reveiw course 2014
anand tiwari reveiw course 2014
EUROTHERM3235
Recruitment321 patients have now been recruited tothe trial. Thank you for continuing to enrol!
HBOT
Stem cell transplant
anand tiwari reveiw course 2014
Thank you
anand tiwari reveiw course 2014
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