Severe Traumatic Brain Injury Francesco Della Corte, MD Associate Professor University A' Avogadro,

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Severe Traumatic Brain Injury Francesco Della
Corte, MDAssociate Professor University A.
Avogadro, School of MedicineNovara, Italy
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• On the site of accident 3.30 pm

• MVA
• High speed
• Deformity on the left side

• Male 34 yrs old
• GCS 6 (V1 E1 M4)
• Pupil size unequal (left gt right - not reactive)
• Gasping
• Abdominal distension
• Fracture of the left leg
• RSI, ETI, sedation and volemic infusion

Francesco Della Corte, MD
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• At the ED at 4.30

• GCS 6 (V1 E1 M4)
• Pupil size unequal (left gt right - not reactive)
• Left eyelid contusion and bulb rotated left and
  downward
• Flexion at the right arm to pain
• 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

Francesco Della Corte, MD
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Rescue /transport
E.R.
O.R.
Diagnosis
ICU
5
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?

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• Out of the OR 5.45 pm

The Case Contd

• 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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CT scan
Francesco Della Corte, MD
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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 1265-266, 1971
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries
the role and prevention of cerebral ischemia
Vasospasm
Arterial hypotension
Intracranial hypertension
Postraumatic cerebral ischemia
Focal compression due to intracerebral or
extrassial hematomas
Brain swelling or Cerebral edema
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries
the role and prevention of cerebral ischemia
CBF ml/100g/min
.
.
.
45
Time course and CBF in head injury
40
.
35
.
30
.
.
.
.
.
25
20
I II III
Phase
Day
0 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
11
Pbp O2
Priorities in the treatment of severe head
injuries
the role and prevention of cerebral ischemia
Glutamate
Days after TBI
mM in CSF
Van den Brink, Neurosurgery 46 868-878, 2000
Yamamoto Acta Neurochir S75 31-34, 1999
12
Elevation of microdialysate lactate concentration
after head injury
Priorities in the treatment of severe head
injuries
the role and prevention of cerebral ischemia
Fig. 3 up
1day 2 day
3 day 4 day
5 day
Goodman JC, Crit care med 27 1965-1973, 1999
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries

• The ABCs

Airway patency Breathing Circulation Disability
Exposure
Antioxidants Barbiturates Calcium
antagonists Dexamethasone E vitamine
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries the ABCs
Airways patency
Francesco Della Corte, MD
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Airway patency
ABCs

• Guidelines
• Hypoxemia (apnea, cyanosis or arterial hemoglobin
  O2 saturation lt 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 lt
  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

BTF AANS - 2000
Francesco Della Corte, MD
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ABCs
Airway patency

• Early endotracheal intubation
• Indications
• 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
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ABCs
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
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ABCs
Is preH ETI an absolute priority in the
management of the HI?

• Murray JA J Trauma. 2000 Dec49(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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Brescia 2, Lecco, Milano Niguarda, Milano
Policlinico, Milano San Raffaele, Monza, Pavia
2, Roma, Sondalo, Varese
18 CENTERS3 months
Torino CTO
Trieste
Treviso, Vicenza
Bologna Bellaria, Cesena
Ancona
Genova Galliera
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
20
Pre-H intubation
ABCs
Is preH ETI an absolute priority in the
management of the HI?
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
21
Priorities in the treatment of severe head
injuries the ABCs
Breathing
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries ABCs

• All intubated patients must be ventilated to
  obtain
•  
• adequate oxygenation (paO2 gt 90 mmHg, SaO2 gt
  95)
• prevention of hyper- or hypocapnia, with PaCO2
  at 35 mmHg

• BUT should they be
• hyperventilated or not to hyperventilated?

Recommendations for the treatment of adults with
severe head trauma (Part I) Min. Anest. 5,1999
23

• Priorities in the treatment of severe head
  injuries When to hyperventilate or not to
  hyperventilate?

40
35
CBF ml/100 g/min
30
25
186 pts (Bouma 1991) (Robertson 1992 Jaggi
1990 Marion 1991, Martin 1997)
20
lt 6
gt 48
6-12
12-18
18-24
24-30
30-36
36-42
42-48
Francesco Della Corte, MD
Hours post injury
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Priorities in the treatment of severe head
injuries ABCs
Standards In the absence of increased ICP
chronic prolonged hyperventilation (25 mmHg or
less) should be avoided Guidelines
prophylactic hyperventilation (lt35 mmHg)
during the first 24 hours should be
avoided Options 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 alJ Neurotrauma,
17513-520, 2000
25
Priorities in the treatment of severe head
injuries the ABCs
Circulation
Francesco Della Corte, MD
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Mortality (SHI at time of arrival at ER) 36.6
0
10
20
30
40
50
60
70
80
90
100
699 patients
Mortality
Chesnut RM et al. J trauma 1993 34216-222
Francesco Della Corte, MD
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Secondary insults first 24 hrs
None
Hypoxia
Hypotension
Both
Mutually exclusive
Hypotension SBP ? 90 mmHg or cyanosis or no
peripheral pulse Hypoxia SaO2 ? 90 or apnea or
cyanosis
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
Francesco Della Corte, MD
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Secondary insults - GOS 6 months
1
2
GOS
3
4
5
Hypotension SBP ? 95 mmHg or cyanosis or No
peripheral pulse Hypoxia SaO2 ? 90 or apnea or
cyanosis
(c20.001)
0
50
100
150
200
250
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
Francesco Della Corte, MD
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Hypotension and Head Injury
Manley G,Arch Surg. 2001
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries ABCs
Circulation
Hypoxemia (lt90 arterial hemoglobin oxygen
saturation or apnea, cyanosis or a paO2 lt 60
mmHg) Hypotension (lt90 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
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries ABCs
Circulation
What 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
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries ABCs Circulation
What is the optimal target for BP?

keep systolic BP gt 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
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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
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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
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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
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Priorities in the treatment of severe head
injuriesWhat about sedation?

MIDAZOLAM  Deo S The use of midazolam in trauma
resuscitation. Eur J Emerg Med. 1994
Sep1(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-Jun5(2)163-8.   .The use of midazolam
with prehospital RSI is associated with a
dose-related incidence of hypotension.
Francesco Della Corte, MD
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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 Apr57(4)361-8. 2
Schockenhoff B Use of etomidate within the scope
of neurosurgery Zentralbl Neurochir.
198546(2)151-5. German. 3 Hinds CJ.
Etomidate and adrenocortical function. Intensive
Care Med. 198410(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 Jul38 Suppl47-50. 5 Prior JG The use
of etomidate in the management of severe head
injury. Intensive Care Med. 19839(6)313-20.
6 Schulte am Esch J, The influence of
etomidate and thiopentone on the intracranial
pressure elevated by nitrous oxide. Anaesthesist.
1980 Oct29(10)525-9. German.
38
Priorities in the treatment of severe head
injuries What about sedation?

KETAMINE  Bourgoin A.  Safety of sedation with
ketamine in severe head injury patients
comparison with sufentanil. Crit Care Med. 2003
Mar31(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.
Francesco Della Corte, MD
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Priorities in the treatment of severe head
injuries What about sedation?

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
Francesco Della Corte, MD
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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 for BP? 
• What about sedation?
• How much to rely on the first CT for further
  developments and prognosis ?

Francesco Della Corte, MD
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CT scan 12 hrs later
Francesco Della Corte, MD
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Timing of CT scan
How much to rely on the first CT for further
developments and prognosis?

• 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

Recommendations for the treatment of adults with
severe head trauma (Part I) Min. Anest. 5,1999
43
How much to rely on the first CT for further
developments and prognosis ?
Initial scan vs
Worst scan
DI I - DI II - DI III - DI
IV - Mass lesion
DI I 89 4 2
0 4
DI II 81 4
1 14
DI III 85
1 13
DI IV
80 20
Mass lesion
100
Francesco Della Corte, MD
Servadei et al Neurosurgery, Vol 46, n.1, January
2000
44
Which patients are at high risk for ICP elevation?
45
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
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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
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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
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