Severe Traumatic Brain Injury Francesco Della Corte, MD 1
Transcript
Severe Traumatic Brain Injury Francesco Della Corte, MD 1
1 Severe Traumatic Brain Injury Francesco Della Corte, MD •On the site of accident 3.30 pm •MVA •High speed •Deformity on the left side Severe Traumatic Brain Injury Francesco Della Corte, MD Associate Professor University A. Avogadro, School of Medicine Novara, Italy •Male 34 yrs old •GCS 6 (V1; E1; M4) •Pupil size unequal (left > right - not reactive) •Gasping •Abdominal distension •Fracture of the left leg •RSI, ETI, sedation and volemic infusion Francesco Della Corte, MD •At the ED at 4.30 •GCS 6 (V1; E1; M4) •Pupil size unequal (left > right - not reactive) •Left eyelid contusion and bulb rotated left and downward •Flexion at the right arm to pain Rescue /transport •AP 73/43 mmHg; HR 135 bpm •SpO2 100%; Hb 4.5 g/dl •Abdominal US: positive •Chest Xray (multiple left chest rib fractures) •Transported immediately in the OR for splenectomy Diagnosis E.R. O.R. ICU Francesco Della Corte, MD Key Questions • Priorities in the treatment of severe head injuries: • the role and prevention of cerebral ischemia • The ABCs • Is preH ETI an absolute priority in the management of the STBI? • When to hyperventilate or not to hyperventilate? • What is the gold target for BP? • What about sedation in severe HI? • How much to rely on the first CT for further evolution and prognosis? •Out of the OR 5.45 pm The Case Cont’d •Sedation and analgesia •(propofol 2.5 mg/Kg/h & remifentanyl 0.05 mcg/kg/min) •GCS 6 (V1; E1; M4) + persisting pupils unequal •BP 125/76 mmHg; HR 95 bpm •SpO2 100%; Hb 9.5 g/dl •CT scan 2 Severe Traumatic Brain Injury Francesco Della Corte, MD CT scan Priorities in the treatment of severe head injuries: • the role and prevention of cerebral ischemia •Prognosis of HI is strictly related to: •degree •duration of cerebral ischemia More than 90% of authopsies in HI showed ischemic lesions of different severity Graham D.I., Adams J.H. Ischemic brain damage in fatal head injuries. Lancet 1:265-266, 1971 Francesco Della Corte, MD Francesco Della Corte, MD Priorities in the treatment of severe head injuries: Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemia the role and prevention of cerebral ischemia CBF ml/100g/min 45 Vasospasm 40 Arterial hypotension Intracranial hypertension . . . Time course and CBF in head injury . 35 30 Postraumatic cerebral ischemia 25 20 Brain swelling or Cerebral edema I Phase Focal compression due to . . . . II . . III Day intracerebral or extrassial 0 hematomas 1 2 3 4 5 6 7 8 9 10 11 12 13 Martin NA, Patwardhan RV, et al: Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm.J Neurosurg 87: 9-19, 1997 Francesco Della Corte, MD Priorities in the treatment of severe head injuries: Priorities in the treatment of severe head injuries: the role and prevention of cerebral ischemia the role and prevention of cerebral ischemia Glutamate Pbp O2 mM in CSF Days after TBI Elevation of microdialysate lactate concentration after head injury 16 14 Fig. 3 up 12 10 8 6 4 2 0 Day 1 Day 2 Day 3 Day 4 1day Van den Brink, Neurosurgery 46; 868-878, 2000 Yamamoto: Acta Neurochir S75: 31-34, 1999 2 day 3 day Goodman JC, Crit care med 27; 1965-1973, 1999 4 day Francesco Della Corte, MD 5 day 3 Severe Traumatic Brain Injury Francesco Della Corte, MD Priorities in the treatment of severe head injuries: Priorities in the treatment of severe head injuries: the ABCs • The ABCs Antioxidants Barbiturates Calcium antagonists Dexamethasone E vitamine Airway patency Breathing Circulation Disability Exposure Airways patency Francesco Della Corte, MD Francesco Della Corte, MD ABCs ABCs Airway patency Airway patency • Guidelines Early endotracheal intubation • Hypoxemia (apnea, cyanosis or arterial hemoglobin O2 saturation < 90%) must be avoid, if possible, or corrected immediately… Hypoxemia should be corrected by administering supplemental oxygen • Options • The AW should be secured in patients with GCS < 9, with inability to maintain an adequate airway or hypoxemia not corrected by supplemental O2. • Endotracheal intubation, if available, is the most effective procedure to maintain the airway Indications: • • • • • BTF – AANS - 2000Francesco Della Corte, MD ABCs Airway obstruction in any case Maintainance of an adequate oxygenation and ventilation Prevention of hyper and hypocapnia Protection of airways obstruction Prevention of neurological deterioration in hostile environments (transport, radiological procedures) Francesco Della Corte, MD ABCs Is preH ETI an absolute priority in the management of the HI? Airway patency • Orotracheal intubation should be preferred • Blind nasotracheal intubation is to be avoided: • In any case a fracture of the basis (and maxillar) is suspected It needs the patient breaths spontaneously High percentage of failures It could give nasal bleeding (obstacle to orotracheal intubation) • A cervical spine lesion must ever be suspected in a a comatose patient. Treat him/her as having a spine injury Francesco Della Corte, MD • Murray JA J Trauma. 2000 Dec;49(6):1065-70. Prehospital intubation in patients with severe head injury. • For patients with severe head injury, prehospital intubation did not demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results. • Bochicchio GV J Trauma 2003 Feb; 54(2): 307-11. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. • Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. Francesco Della Corte, MD 4 Severe Traumatic Brain Injury Francesco Della Corte, MD Brescia 2°, Lecco, Milano Niguarda, Milano Policlinico, Milano San Raffaele, Monza, Pavia 2°, Roma, Sondalo, Varese 18 CENTERS 3 months ABCs Is preH ETI an absolute priority in the management of the HI? Pre-H intubation 80 Torino CTO 1300 50 40 Bologna Bellaria, Cesena 1100 Genova Galliera 1000 N 60 Treviso, Vicenza 1200 Y 70 Trieste Ancona 30 20 Patients 10 0 Roma Gemelli G. Citerio, N. Stocchetti, M. Cormio , L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp 769-776 Priorities in the treatment of severe head injuries: the ABCs 3 4 5 6 7 8 GCS G. Citerio, N. Stocchetti, M. Cormio , L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp 769-776 Priorities in the treatment of severe head injuries: ABCs All intubated patients must be ventilated to obtain: • adequate oxygenation (paO2 > 90 mmHg, SaO2 > 95%) • prevention of hyper- or hypocapnia, with PaCO2 at 35 mmHg Breathing BUT should they be hyperventilated or not to hyperventilated? Francesco Della Corte, MD Priorities in the treatment of severe head injuries: When to hyperventilate or not to hyperventilate? Recommendations for the treatment of adults with severe head trauma (Part I) – Min. Anest. 5,1999 Priorities in the treatment of severe head injuries: ABCs Standards: 40 35 Guidelines: prophylactic hyperventilation (<35 mmHg) during the first 24 hours should be avoided 30 Options: 25 42-48 > 48 36-42 30-36 18-24 24-30 (Robertson 1992; Jaggi 1990; Marion 1991, Martin 1997) 12-18 20 186 pts (Bouma 1991) <6 6-12 CBF ml/100 g/min In the absence of increased ICP chronic prolonged hyperventilation (25 mmHg or less) should be avoided Hours post injury Francesco Della Corte, MD Hyperventilation may be necessary for brief periods when there is neurologic deterioration, or for longer if there is intracranial hypertension refractory to sedation, paralysis, CSF drainage and osmotic diuretics. Brain Trauma Foundation, et al:J Neurotrauma, 17:513-520, 2000 5 Severe Traumatic Brain Injury Francesco Della Corte, MD Priorities in the treatment of severe head injuries: the ABCs Mortality (SHI at time of arrival at ER) = 36.6 % Neither 27 % Hypoxia Circulation 33 % Hypotension 60 % Both 75 % 0 699 patients 10 20 30 40 50 60 70 80 90 100 Mortality % Francesco Della Corte, MD Chesnut RM et al. J trauma 1993; 34:216-222 Francesco Della Corte, MD Secondary insults - GOS 6 months Secondary insults first 24 hrs None 19% 1 52% 2 3 None 14% 58% Hypoxia Hypoxia 25% 5 Hypotension Both Mutually exclusive 11% 0 100 200 300 18% 400 500 Hypotension = SBP ≤ 90 mmHg or cyanosis or no peripheral pulse Hypoxia = SaO2 ≤ 90 or apnea or cyanosis 54% Hypotension Both Francesco Della Corte, MD Hypotension and Head Injury Hypotension = SBP ≤ 95 mmHg or cyanosis or No peripheral pulse Hypoxia = SaO2 ≤ 90 or apnea or cyanosis 26% 51% 0 G. Citerio, N. Stocchetti, M. Cormio , L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp 769-776 GOS 4 44% 18% 50 (χ20.001) 100 150 G. Citerio, N. Stocchetti, M. Cormio , L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp 769-776 200 250 Francesco Della Corte, MD Priorities in the treatment of severe head injuries: ABCs Circulation p= 0.009 Hypoxemia (<90% arterial hemoglobin oxygen saturation or apnea, cyanosis or a paO2 < 60 mmHg) Hypotension (<90 mmHg systolic blood pressure) are significant parameters associated with a poor outcome in patients with STBI in the prehospital setting Guidelines for Prehospital Management of TBI. BTF, 1999 Manley G,Arch Surg. 2001 Francesco Della Corte, MD Francesco Della Corte, MD 6 Severe Traumatic Brain Injury Francesco Della Corte, MD Priorities in the treatment of severe head injuries: ABCs Circulation W hat Priorities in the treatment of severe head injuries: ABCs Circulation is the optimal target for BP? •CPP should be maintained at greater than 60 mmHg in adults •CPPs of 50 mmHg or lower have been shown to be associated with critical reductions and with increased mortality following severe TBI •No study has found that the incidence of intracranial hypetension, morbidity or mortality is increased by the active maintainance of CPP above 60 mmHg •…. Artificial attempts to maintain CPP above 70 mmHg may be associated with an increase incidence of ARDS Guidelines for the management of STBI: CPP - BTF – AANS March 14,2003 What is the optimal target for BP? keep systolic BP > 110 mmHg in adults to ensure adequate cerebral perfusion pressure Recommendations for the treatment of adults with severe head trauma (Part I) – Min. Anest. 5,1999 Francesco Della Corte, MD Priorities in the treatment of severe head injuries: ABCs Is MAP a better endpoint than systolic BP? The value of 90 mmHg SBP to delineate the threshold for hypotension has arisen arbitrarirly and is more statistical than a physiologic parameter….. It may be valuable to maintain MAP considerably above those represented by SBP of 90 mmHg… Guidelines for Prehospital Management of TBI. BTF, 1999 Francesco Della Corte, MD Priorities in the treatment of severe head injuries: What about sedation? Recommended sedation protocol for ETI in TBI – Italian guidelines, 1999 • Midazolam 0.1-0.2 mg/kg or • Propofol 1-2 mg/kg iv (attention to hypotension) if hypotensive or bleeding thiopental 1 mg/kg or midazolam 0.05-0.1 mg/kg; Succinylcholine 1 mg/kg iv. or vecuronium 0.1 mg/kg iv. Sedation/analgesia should be continued, using short-acting drugs so that neurological assessments can be made at regular intervals in the ED. Muscle relaxing drugs should be avoided if possible. Francesco Della Corte, MD Francesco Della Corte, MD Key Questions • Priorities in the treatment of severe head injuries: • the role of cerebral ischemia • ABCs • Is preH ETI an absolute priority in the management of the HI? • To hyperventilate or not to hyperventilate? • What is the gold target of BP? • What about sedation? • How much to relay on the first CT for further developments? Francesco Della Corte, MD Priorities in the treatment of severe head injuries: What about sedation? MIDAZOLAM Deo S The use of midazolam in trauma resuscitation. Eur J Emerg Med. 1994 Sep;1(3):111-4. …… Midazolam was found to be a safe and viable alternative to muscle relaxants, allowing endotracheal intubation and ventilation Davis DP Prehosp Emerg Care. 2001 Apr-Jun;5(2):163-8. …….The use of midazolam with prehospital RSI is associated with a dose-related incidence of hypotension. Francesco Della Corte, MD 7 Severe Traumatic Brain Injury Francesco Della Corte, MD Priorities in the treatment of severe head injuries: What about sedation? Priorities in the treatment of severe head injuries: What about sedation? ETOMIDATE 1: Dearden NM Comparison of etomidate and althesin in the reduction of increased intracranial pressure after head injury. Br J Anaesth. 1985 Apr;57(4):361-8. 2: Schockenhoff B Use of etomidate within the scope of neurosurgery Zentralbl Neurochir. 1985;46(2):151-5. German. 3: Hinds CJ. Etomidate and adrenocortical function. Intensive Care Med. 1984;10(5):268-9. 4: Cohn BF Results of a feasibility trial to achieve total immobilization of patients in a neurosurgical intensive care unit with etomidate. Anaesthesia. 1983 Jul;38 Suppl:47-50. 5: Prior JG The use of etomidate in the management of severe head injury. Intensive Care Med. 1983;9(6):313-20. KETAMINE Bourgoin A. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003 Mar;31(3):711-7 …… ketamine in combination with midazolam is comparable with a combination of midazolam-sufentanil in maintaining intracranial pressure and cerebral perfusion pressure of severe head injury patients placed under controlled mechanical ventilation. 6: Schulte am Esch J, The influence of etomidate and thiopentone on the intracranial pressure elevated by nitrous oxide. Anaesthesist. 1980 Oct;29(10):525-9. German. Priorities in the treatment of severe head injuries: What about sedation? Francesco Della Corte, MD Key Questions • Priorities in the treatment of severe head injuries: LIDOCAINE EV lidocaine prevents the increase in ICP that occur during ETI Many RSI protocols include L several minutes before laringoscopy No literature could be found to support the use of L as a single agent prior intubation • the role of cerebral ischemia • ABCs • Is preH ETI an absolute priority in the management of the HI? • To hyperventilate or not to hyperventilate? • What is the gold target for BP? • What about sedation? Francesco Della Corte, MD CT scan 12 hrs later • How much to rely on the first CT for further developments and prognosis ? Francesco Della Corte, MD How much to rely on the first CT for further developments and prognosis? Timing of CT scan • First CT as soon as possible • Second CT • before 12 hrs if first within 3 hrs after trauma • within 24 hrs • Third CT before 72 hrs after the trauma A CT scan must be obtained in case of any clinical deterioration or increase in ICP Francesco Della Corte, MD Recommendations for the treatment of adults with severe head trauma (Part I) – Min. Anest. 5,1999 8 Severe Traumatic Brain Injury Francesco Della Corte, MD How much to rely on the first CT for further developments and prognosis ? Initial scan DI I DI I 89% DI II vs - DI II 4% 81% DI III - DI III Which patients are at high risk for ICP elevation? Worst scan - DI IV 2% - Mass lesion 0% 4% 4% 1% 14% 85% 1% 13% 80% 20% DI IV Mass lesion 100% Servadei et al Neurosurgery, Vol 46, n.1, January 2000 Francesco Della Corte, MD Clinical case: outcome • The patient remained in the ICU 9 days. • He had intermittent increases of ICP during the first 4 days responsive to medical treatment • He was operated at the left leg on day 4 • He was extubated on day 8 • He was transferred to Neurosurgical ward and now he came back to his work with only a minor paresis of the left arm Francesco Della Corte, MD Conclusions No single “magic bullet” has been developed The cornerstone of management of head-injured patients remains the prevention of initial injury and the minimization or reversal of secondary insults Teasdale GM Neurosurgery 1998 Francesco Della Corte, MD Conclusions • Brain ischemia is the most relevant pattern in STBI especially in the first 24 hrs. • Head injured patients require aggressive approach in the acute phase for the prevention of secondary insults. Hypoxia and hypotension are the most frequent, important (and preventable) complications • Referral to hospitals with neurosurgical facilities should be the gold standard where surveillance, diagnosis and prompt surgical intervention could be provided in case of detection of mass lesion Francesco Della Corte, MD