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ICU Management of Traumatic Brain Injury
ConcussionContusionff lDiffuse Axonal Inury
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%
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?
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?
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
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
Minor Head Injury‐GCS= 14Elevate HOBNeurochecks q 1 or q 2 hrsNPO until alertNormal SalineMild analgesiagAntiemetic‐Tigan
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.
Principles:
Cerebral Perfusion Pressure = MAP‐ICP
Secondary Injury
l b l fIntracranial Pressure vs Cerebral Perfusion Pressure
Normal CPP > 50 mm Hg
As long as CPP>60 mm Hg, higher CPP does b l dnot protect brain against elevated ICP.
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.
IndicationsNeurologic criteriaMultiple systems injured that may affect ICPTraumatic Intracranial Mass (EDH, SDH)Fulminant Liver Failure with Factor VII
fInfectionHemorrhage
lf bMalfunction/obstructionMalposition
Most accurateAllows fluid release to treat ICP elevationLower cost
Camino or Honeywell/PhillipsMore expensiveMeasurement Drift
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
Check output every hourCheck function every hour
flOverflowSet zero point
bl h blTroubleshoot problems
Jugular Venous Oxygen MonitoringBrain Tissue Oxygen Tension Monitoring
d d f lBedside Monitoring of Regional CBF
F ICP H d k CPP HFor ICP> 20 mm Hg, and keep CPP>70 mm Hg
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
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
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
More of these‐
Means less of these!!!
And More of these
l f hMeans less of these!!!