Title: Optimizing ED Management of Severe Traumatic Brain Injury: A Diagnosis
1Optimizing ED Management of Severe Traumatic
Brain InjuryA Diagnosis Treatment Protocol
2Scott Weingart, MDAssistant ProfessorDirector
of ED Critical CareElmhurst Hospital
CenterMount Sinai School of MedicineNew York, NY
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4Objectives
- Improve pt outcome in TBI
- Minimize secondary injury of TBI patients
- Improve monitoring of TBI
- Improve treatment of TBI
- Improve knowledge of TBI prognosis
- Improve emergency medicine practice
5A Clinical Case
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8Suspected TBI
from trauma.org imagebank
9Assess the GCS and Pupillary Response
TBI Procedure
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11Maintain MAP gt90
TBI Procedure
12 Since CPPMAP ICPand ICP is assumed to be
elevated we must maintain MAP to maintain CPP.
Its all about Perfusion
13Maintain Sat gt95
TBI Procedure
14Intubate if the GCSlt9 or you suspect the patient
may decompensate
TBI Procedure
15Neuroprotective Intubation
- Pretreatment Meds
- Lidocaine
- Fentanyl
- Defasiculating Dose Paralytic
- MAP Stable Dose of Sedative
- Paralytic
- Skilled Intubater
16Avoid Prophylactic HyperventilationKeep CO2
between 35-38
TBI Procedure
17If pt is showing signs of impending herniation,
we may hyperventilate to 30 for a brief period of
time
Hyperventilation
18Signs of Increasing ICP
- Unilateral or bilateral unreactive, dilated pupil
- Extensor posturing (decerebrate)
- A sharp decline in GCS
19Mannitol1.2-1.4 g / kg
TBI Procedure
20Confirmed TBI
21Continue to Maintain MAPContinue to Maintain
SatsContinue to Maintain CO2
TBI Procedure
22Introduce the patient to a Neurosurgeon
TBI Procedure
23Monitor ETCO2
TBI Procedure
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26Keep PaCO2between 35-38Treat EtCO2 gt35
ETCO2
27Push Na to 150Never lt 140
TBI Procedure
28Na in Resus Fluids
29Head of the Bed to 45
TBI Procedure
30Temp lt100 F
TBI Procedure
31Serum Osm lt 320
TBI Procedure
32Monitor Urine OutputKeep Fluid Balance
TBI Procedure
33Administer Adequate Sedation Pain Control
TBI Procedure
34Early AppropriateICP Monitoring
TBI Procedure
35ICP Monitor Indications
- GCS (3-8) with abnormal head CTs
- GCS (3-8) with normal CTs and two of the
following - SBPlt90
- Posturing
- Agegt40
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39Blaivas M et al. Elevated intracranial pressure
detected by bedside emergency ultrasonography of
the optic nerve sheath. Acad Emerg Med. 2003
Apr10(4)376-81.
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41CPPMAP ICPKeep ICP lt 20Keep CPP gt 60
ICP Monitoring
42Treat ? ICP
TBI Procedure
43Mannitol Boluses1 g / kg over 10
minutesReplace all Urinary Output
ICP Treatment
44Hypertonic Saline250 cc 3 over 10 minutes
ICP Treatment
45Treat ? CPP
TBI Procedure
46FluidsBloodInotropesPressors
CPP Treatment
47Dilantin Load20 mg/kg over 1 hour
TBI Procedure
48Admit to a NeuroCriticalCare Bed
TBI Procedure
49Patient Outcome
- Decompressive Craniectomy
- Decompressive Laparotomy
- 4 Weeks In NTICU
- Received Tracheostomy
- Weaned off Vent
- Transferred to Floor
- Intensive OT/PT/Psych Support
- Came to visit at 7 monthsFully Intact
50Further Reading
- Guidelines for the Management and Prognosis of
Severe Traumatic Brain Injury. http//www.braintra
uma.org - International Trauma Forum. http//www.trauma.org
51Questions?? www.ferne.orgferne_at_ferne.orgScot
t Weingart, MDgatsby_at_eudoramail.com817.977.3384
Ferne_2006_aaem_sa_weingart_bic_spine.ppt