1What is the tool used to assess consciousness in TBI?
GCS
2GCS
What are the three components?
What is the interpretations of scores?
- Motor response, verbal response, eye opening response
- Lowest score = 3 (completely unresponsive)
- Highest score = 15
3TBI Severity
What GCS score would indicate mild severity?
13-15
4TBI Severity
What GCS score would indicate moderate severity?
9-12
5TBI Severity
What GCS score would indicate severe severity?
3-8
6TBI Severity
T/F: Mild TBIs will still have abnormal imaging.
FALSE -- If there is any abnormal imaging = moderate or severe
7TBI
What are the types of TBIs?
- Epidural hematoma (EDH)
- Subdural hematoma (SDH)
- Subarachnoid hemorrhage (SAH)
- Intraparenchymal hemorrhage (IPH)
- Shear injury
- Diffuse edema
8TBI
What are the modifiable risk factors for poor neurologic outcomes in TBI patients that should be avoided to prevent additional secondary (further) brain injury?
- Hypotension (SBP < 90 mmHg)
- Hypoxia (low oxygen saturation)
- Coagulopathy (from medications or due to TBI)
- Seizures
- Hyperglycemia / hypoglycemia
9TBI - Hemodynamic Management
T/F: The lower the SBP is at presentation, the higher the mortality rate is.
TRUE = AVOID hypotension in patients with TBI
10TBI - Hemodynamic Management
If the patient is hypotensive at presentation, what is the first step to manage?
Fluid/volume/ blood resuscitation
- Normal saline preferred
11TBI - Hemodynamic Management
What fluid product should NOT be used in TBI due to increased mortality?
Albumin
12TBI - Hemodynamic Management
What should be given if the patient is unresponsive to initial fluid resuscitation?
Vasopressors
- NE or phenylephrine
13TBI - Hemodynamic Management
What are the BP goals while treating TBI patients?
- SBP ≥ 100 mmHg for ages 50-69 years old
- SBP ≥ 110 mmHg for ages 15-49 years old or > 70 years old
14TBI - Coagulopathy
What is the type of coagulopathy observed in trauma and TBI?
Hyperfibrinolysis
15TBI - Coagulopathy
In patients with hyperfibrinolysis, what is the place in therapy for tranexamic acid?
Tranexamic acid given within 3 hrs of injury may reduce head injury-related death in TBI patients
Particular interest in mild to moderate TBI patients
16TBI - Seizure Ppx
Early seizure prophylaxis should be started within ___ days of injury.
7
17TBI - Seizure Ppx
T/F: Continue seizure ppx for as long as the patient is in the hospital.
FALSE -- Do not give longer than 7 days
18TBI - Seizure Ppx
Agents used?
- Levetiracetam
- Phenytoin
19TBI - ICP
What are the two ways to monitor ICP?
Which provides a therapeutic benefit in addition to monitoring?
- External ventricular drain (EVD): Additional benefit to monitoring is the ability to drain CSF to lower ICP
- ICP monitoring "bolt" or Codman: No therapeutic benefit, only monitoring
20TBI - ICP
What is the pressure required to perfuse the brain adequately?
What other two parameters does it depend on?
Cerebral Perfusion Pressure (CPP)
- Depends on MAP and ICP
21TBI - ICP
How do you calculate the CPP?
CPP = MAP - ICP
22TBI - ICP
CPP goal?
60-70 mmHg
23TBI - ICP
What ICP should treatment for ICP reduction be started?
> 20-22 mmHg
24TBI - ICP
What are initial management strategies before starting hyperosmolar therapies?
- Head of bed at 30°
- Avoid excessive fluid resuscitation
- If EVD, unclamp to allow CSF to drain
- Adequate sedation and analgesia: May assist in preventing hypoxia in patients who are difficult to ventilate
25TBI - ICP
What is the preferred sedative in neurologic injury? Why?
Propofol
- ↓ ICP by ↓ metabolic demand
- Quick onset and short duration to allow for frequent neurological examinations
26TBI - ICP
What is the main concern with using propofol in TBI?
It can cause hypotension and we should AVOID hypotension in TBI
- May require pressors
27TBI - ICP
What are the two hyperosmolar agents used in TBI?
What agent is more commonly used in practice and recommended?
- Mannitol
- Hypertonic saline: Preferred agent
28TBI - ICP
T/F: If ICP is not being monitored, it is still okay to give hyperosmolar therapy.
FALSE -- No ICP monitoring = No hyperosmolar therapy
29Hyperosmolar Therapy - Mannitol
MOA?
Osmotic diuretic = Pulls water from the tissues into the vasculature
30Hyperosmolar Therapy - Mannitol
How is it dosed?
0.25 to 1 g/kg in bolus doses up to Q6 hrs prn ICP > 22 mm Hg given over 30 minutes
- AVOID continuous infusion
31Hyperosmolar Therapy - Mannitol
What should always be check before administering this?
Crystallization
32Hyperosmolar Therapy - Mannitol
Monitoring parameters?
- ICP for reaching goal ≤ 20 mmHg
- Blood osmolality up to Q6 hrs (280 mOsm/kg normal but max for therapeutic purposes 320-325 mOsm/kg)
- Fluid status, blood pressure (avoid SBP < 100 mmHg), osmole gap (predictor of AKI)
33Hyperosmolar Therapy - Mannitol
What are two situations this should not be used?
- Hypovolemia
- Hypotensive
34Hyperosmolar Therapy - Hypertonic Saline
MOA?
Builds up sodium gradient across BBB to pull fluid from CNS = Increases blood osmolality by increasing sodium
- Additional MOA = Dehydrates endothelial cells/erythrocytes and decrease inflammatory damage
35Hyperosmolar Therapy - Hypertonic Saline
What may this also improve while decreasing ICP?
Hemodynamics because is it a small volume fluid resuscitation
36Hyperosmolar Therapy - Hypertonic Saline
What are the dose forms? How is it administered?
- 3% sodium chloride (513 mEq/L) , 5% sodium chloride (856 mEq/L) , 7.5% sodium chloride (1283 mEq/L)
- Treat ICP with bolus doses of the above (usually 125-250 mEq NaCl) over 10 minutes to 1 hour
37Hyperosmolar Therapy - Hypertonic Saline
Monitoring parameters?
- ICP for reaching goal ≤ 20 mmHg (sometimes will just have a sodium goal of above 150 mEq/L)
- Sodium up to Q6h to ensure not going over the therapeutic max of 160 mEq/L
- Osmolality to ensure not going over therapeutic max of 320-325 mOsm/kg
- Osmotic demyelination syndrome (only true if pt presented hyponatremic) if raise sodium too fast (>10-12 mEq/ 24 hrs)
- Hyperchloremia à AKI?
38Hyperosmolar Therapy - Hypertonic Saline
Why is it preferred over mannitol?
- Hypertonic saline may be effective longer than mannitol
- Less "rebound effect" with hypertonic saline
- Combined resuscitation and hyperosmolar therapy
39TBI - Hyperosmolar Therapy
What agent would be best if you need volume with elevated ICP in order to increase BP (↑ MAP )?
Hypertonic saline
40TBI - Hyperosmolar Therapy
What agent should be avoided in a MAP of < 65?
Mannitol
41TBI - Hyperosmolar Therapy
When would mannitol be considered an optimal therapy?
Hemodynamically stable and euvolemic to hypervolemia
42TBI - Hyperosmolar Therapy
What are the sodium and blood osmolality cut off levles for using either agent?
- Na = 160
- Osmolality = 325
43TBI - ICP
What is the salvage ICP reduction agent?
Pentobarbital coma
44TBI - DVT Ppx
When should DVT ppx be started?
LMWH within 24 to 48 hours after presentation in TBI patients
45TBI - DVT Ppx
What is the main consideration before starting DVT ppx in a TBI patient?
Must have hemostasis in the brain before starting
46TBI - DVT Ppx
T/F: DVT ppx should not be started until ICP is less than 22 mmHg.
FALSE -- Still give DVT ppx while ICP is elevated.
47TBI Management
What other type of ppx should be give to TBI patients?
Stress ulcer ppx with H2 blocker or PPI
48Post-Acute TBI
What is the main condition seen due to hyperadrenergic activity due to autonomic dysregulation?
Paroxysmal Sympathetic Hyperactivity
49Post-Acute TBI
What is the treatment for paroxysmal sympathetic hyperactivity?
Propranolol unless hypotensive or bradycardic
50Post-Acute TBI
What agent should be considered for minimally conscious patients or vegetative state within 1 month of injury?
Amantadine
- Increases release of dopamine from nerve terminals in the CNS)
51Post-Acute TBI
What agents should be considered for cognitive dysfunction after TBI?
- Methylphenidate
- Modafinil