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
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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
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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
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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
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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