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Severe Head Injury: Review and update And challenging the concept of best available data

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Sequential compression devices unless prevented by lower extremity injuries. ... at 48 hours after injury (or surgery) if cleared by trauma and neurosurgical teams. ... – PowerPoint PPT presentation

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Title: Severe Head Injury: Review and update And challenging the concept of best available data


1
Severe Head Injury Review and update(And
challenging the concept of best available data)
  • Jeffrey Florman, MD
  • American College of Surgeons
  • 2009

2
Blah blah
  • Lots of head injury
  • Lots of ill people

3
Severe Head Injury
  • GCS 8 or less

4
Outcome
  • For severe CHI (GCSlt8)
  • 36 mortality
  • Quality of life (GCSlt8)
  • Vegetative - 5
  • Severe disability - 16
  • Moderate disability - 16
  • Good - 27

5
Patterns of Injury
  • Primary Injury
  • Occur at the moment of impact
  • Skin/Bones/Meninges/Brain/Blood vessels
  • Secondary Injury
  • Occur after impact
  • Expanding hematomas
  • Brain edema/swelling
  • Hypoxemia/Ischemia/Shock
  • Fever/infection
  • Electrolyte imbalance

6
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7
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8

9
Herniation
10
Surgery
11
Surgery
  • Decompression
  • Removing hematoma
  • Removing injured brain
  • Removing Bone/Foreign Bodies
  • Fracture Repair
  • Repair of Spinal Fluid Leak

12

13

14
Non-surgical Management
  • Secondary Injury
  • Expanding hematomas
  • Brain edema/swelling
  • Hypoxemia/Ischemia/Shock
  • Fever/infection
  • Electrolyte imbalance
  • Seizures
  • Coagulopathy
  • Other non-neurologic (DVT, pneumonia)

15
Lets talk
  • Optimizing care
  • Interpreting The Guidelines
  • Institutional biases
  • ICP/CPP/PBO2

16
The Guidelines for the Management of Severe
Closed Head Injury
  • Challenges Limitations
  • Summary statements
  • Poor data
  • Conservative
  • Not always useful
  • Can limit treatment
  • Strengths
  • Excellent concept
  • Strong effort
  • Big step towards standardizing care
  • Blah blah

17
Data Classification
  • Class 1 Good quality RCTs
  • Class 2 Moderate quality RCTs and good quality
    prospective studies
  • Class 3 Lesser quality trials and case series

18
Levels of Evidence
  • Level 1- based on strongest evidence with high
    degree of clinical certainty
  • Level 2 reflect a moderate degree of clinical
    certainty
  • Level 3 degree of clinical certainty not
    established

19
Blood Pressure and Oxygenation
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Blood pressure should be monitored and
    hypotension (systolic blood pressure 90 mm Hg)
    avoided.
  • Level III - Oxygenation should be monitored and
    hypoxia (PaO2 60 mm Hg or O2 saturation 90)
    avoided.

20
What now?
  • No level 1 evidence
  • Level 2 avoid hypotension
  • Level 3 avoid hypoxemia
  • SBP (90 mmHg) and O2Sat (90) parameters dont
    pass the sniff test
  • Thanks for nothing!
  • Weak advise
  • What do we target?

21
MMC Guidelines for Severe Head Injury
Management
  • Jeffrey Florman, MD
  • Gene Grindlinger, MD

22
MMC Guidelines for Severe Head Injury Management
  • Evidence based
  • Consensus driven
  • Practical indications and targets
  • Institutional consistent paradigm
  • Educational
  • Research friendly by standardizing care
  • Heres a quick look at the guidelines

23
Blood Pressure and Oxygenation
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Blood pressure should be monitored and
    hypotension (systolic blood pressure 90 mm Hg)
    avoided.
  • Level III - Oxygenation should be monitored and
    hypoxia (PaO2 60 mm Hg or O2 saturation 90)
    avoided.

24
Blood Pressure and Oxygenation
  • Avoid hypotension SBPlt90
  • Avoid hypoxia PaO2lt60 or O2Satlt90
  • Steakholders to meet and address this

25
Prophylactic Hypothermia
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - There are insufficient data to support
    a Level II recommendation for this topic.
  • Level III - Pooled data indicate that
    prophylactic hypothermia is not significantly
    associated with decreased mortality when compared
    with normothermic controls. However, preliminary
    findings suggest that a greater decrease in
    mortality risk is observed when target
    temperatures are maintained for more than 48 h.
  • Prophylactic hypothermia is associated with
    significantly higher Glasgow Outcome Scale (GOS)
    scores when compared to scores for normothermic
    controls.

26
Prophylactic Hypothermia
  • Target normothermia (36-38 C)
  • Avoid and treat fever

27
Infection Prophylaxis
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Periprocedural antibiotics for
    intubation should be administered to reduce the
    incidence of pneumonia. However, it does not
    change length of stay or mortality.
  • Early tracheostomy should be performed to reduce
    mechanical ventilation days. However, it does not
    alter mortality or the rate of nosocomial
    pneumonia.
  • Level III - Routine ventricular catheter exchange
    or prophylactic antibiotic use for ventricular
    catheter placement is not recommended to reduce
    infection.

28
Infection Prophylaxis
  • Periprocedural antibiotics for intubation
  • Cefuroxime 1.5 gm x 2 doses within 6 hours of
    intubation
  • Early tracheostomy encouraged
  • Antibiotic impregnated ventricular catheters
    encouraged.
  • Routine ventriculostomy catheter exchange not
    recommended.
  • Prophylactic antibiotics for ventricular
    catheters and ICP monitors not recommended.
    (Procedural single dose prophylaxis at the
    discretion of the surgeon.)

29
DVT Prophylaxis
  • Level I - There are insufficient data to support
    a Level recommendation for this topic.
  • Level II -There are insufficient data to support
    Level recommendation for this topic.
  • Level III - Graduated compression stockings or
    intermittent pneumatic compression stockings are
    recommended, unless lower extremity injuries
    prevent their use. Use should be continued until
    patients are ambulatory.
  • Low molecular weight heparin (LMWH) or low dose
    unfractionated heparin should be used in
    combination with mechanical prophylaxis. However,
    there is an increased risk for expansion of
    intracranial hemorrhage. There is insufficient
    evidence to support recommendations regarding the
    preferred agent, dose, or timing of pharmacologic
    prophylaxis for deep vein thrombosis (DVT).

30
DVT Prophylaxis
  • Sequential compression devices unless prevented
    by lower extremity injuries.
  • Tinzaparin per trauma DVT protocol should be
    added at 48 hours after injury (or surgery) if
    cleared by trauma and neurosurgical teams.
    (Contraindicated if invasive brain monitoring in
    place?)

31
Ventilation
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Prophylactic hyperventilation (PaCO2
    of 25 mm Hg or less) is not recommended.
  • Level III Hyperventilation is recommended as a
    temporizing measure for the reduction of elevated
    intracranial pressure (ICP).
  • Hyperventilation should be avoided during the
    first 24 hours after injury when cerebral blood
    flow (CBF) is often critically reduced.
  • If hyperventilation is used, jugular venous
    oxygen saturation (SjO2) or brain tissue oxygen
    tension (PbrO2) measurements are recommended to
    monitor oxygen delivery.

32
Ventilation
  • Initial target PCO2 mid 30s
  • Transient hyperventilation to PCO2 25-30 if acute
    herniation strongly suggested clinically (i.e.
    blown pupil with SDH en route to OR)
  • Consider trials of hypoventilation to improved
    refractory compromise in PBO2

33
Anticonvulsants
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Prophylactic use of phenytoin or
    valproate is not recommended for preventing late
    posttraumatic seizures (PTS).
  • Anticonvulsants are indicated to decrease the
    incidence of early PTS (within 7 days of injury.)
    However, early PTS is not associated with worse
    outcomes.

34
Anticonvulsants
  • 7 days Fosphenytoin (18-20 mg/kg load and 5 mg/kg
    Q 8 hours maintenence) if any of the following
    GCS 10 or less, intracranial blood (except
    isolated SAH), contusion, depressed skull
    fracture, penetrating head wound, seizure within
    24 h of injury

35
Steroids
  • Level I - The use of steroids is not recommended
    for improving outcome or reducing intracranial
    pressure (ICP). In patients with moderate or
    severe traumatic brain injury (TBI), high-dose
    methylprednisolone is associated with increased
    mortality and is contraindicated.
  • Steroids not recommended.

36
Nutrition
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Patients should be fed to attain full
    caloric replacement by day 7 post-injury.

37
Nutrition
  • Target full caloric replacement by day 7
  • Begin enteral feeds as tolerated by day 1 if not
    contraindicated by other injuries.
  • Begin parenteral nutrition day 2 if not on
    enteral feeds

38
Indications for ICP monitoring
  • Level I - There are insufficient data to support
    a treatment standard for this topic.
  • Level II - Intracranial pressure (ICP) should be
    monitored in all salvageable patients with a
    severe traumatic brain injury
  • (TBI Glasgow Coma Scale GCS score of 38
    after resuscitation) and an abnormal computed
    tomography (CT) scan. An abnormal CT scan of the
    head is one that reveals hematomas, contusions,
    swelling, herniation or compressed basal
    cisterns.
  • Level III - ICP monitoring is indicated in
    patients with severe TBI with a normal CT scan if
    two or more of the following features are noted
    at admission age over 40 years, unilateral or
    bilateral motor posturing, or systolic blood
    pressure (BP) 90 mm Hg.

39
ICP Threshold
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Treatment should be initiated with
    intracranial pressure (ICP) thresholds above 20
    mm Hg.
  • Level III - A combination of ICP values, and
    clinical and brain CT findings, should be used to
    determine the need for treatment.
  • Target ICPlt20

40
Cerebral Perfusion Pressure (CPPMAP-ICP)
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Aggressive attempts to maintain
    cerebral perfusion pressure (CPP) above 70 mm Hg
    with fluids and pressors should be avoided
    because of the risk of adult respiratory distress
    syndrome (ARDS).
  • Level III - CPP of 50 mm Hg should be avoided.
    The CPP value to target lies within the range of
    5070 mm Hg. Patients with intact pressure
    autoregulation tolerate higher CPP values.
  • Ancillary monitoring of cerebral parameters that
    include blood flow, oxygenation, or metabolism
    facilitates CPP management.

41
Cerebral Perfusion Pressure
  • Target CPPgt60
  • Treat hypotension
  • Target ICPlt20

42
Brain Oxygen Monitoring and Thresholds
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - There are insufficient data to support
    a Level II recommendation for this topic.
  • Level III - Jugular venous saturation (50) or
    brain tissue oxygen tension (15 mm Hg) are
    treatment thresholds. Jugular venous saturation
    or brain tissue oxygen monitoring measure
    cerebral oxygenation.

43
Brain Oxygen Monitoring and Thresholds
  • Target PBO2gt20

44
ICP Management Hyperosmotic Therapy
  • Level I - There are insufficient data to support
    a Level I recommendation for this topic.
  • Level II - Mannitol is effective for control of
    raised intracranial pressure (ICP) at doses of
    0.25 gm/kg to 1 g/kg body weight. Arterial
    hypotension (systolic blood pressure 90 mm Hg)
    should be avoided.
  • Level III -Restrict mannitol use prior to ICP
    monitoring to patients with signs of
    transtentorial herniation or progressive
    neurological deterioration not attributable to
    extracranial causes.

45
ICP Management Hyperosmotic Therapy
  • Mannitol
  • Hypertonic saline option
  • Consider over mannitol if patient under active
    resuscitation
  • Contraindicated if patient hyponatremic
  • Tolerate Na up to 160

46

47
Seizures
  • Generalized
  • Focal
  • Big spectrum of presentation
  • Can explain generalized decline in function ,
    increased ICP, and decreased PBO2 without being
    clinically overt

48
Fluids
  • Prefer Normal Saline resuscitation
  • PRBC resuscitation as clinically indicated
  • Prefer maintenance IVF Normal Saline with 20meq/L
    KCl
  • Avoid neck lines

49
Hematology
  • Target INRlt1.5 and PTTlt35
  • Target Platelets gt100
  • Target HCT gt30? (This may not be target if PBO2
    monitored.)
  • The role of transfusion needs careful and
    individualized consideration.

50
Head Position
  • Nurse with head elevated 30 degrees with neutral
    neck position

51
Glucose
  • Target serum glucose lt130 mg
  • Insulin drip per Yale protocol for diabetics or
    hyperglycemia
  • Give glucose for glucose lt60 mg

52
Electrolytes
  • Sodium target 130-160

53
Levels of Evidence
  • Level 1- based on strongest evidence with high
    degree of clinical certainty
  • Level 2 reflect a moderate degree of clinical
    certainty
  • Level 3 degree of clinical certainty not
    established

54
Testing the methods... Florman Style
  • Humans came from water.
  • Humans are about 2/3 water.
  • Swimming and soaking in water feels good.
  • Flormans Theory 612
  • Its good for you to soak in water.

55
The evidence
  • 1. Women take more baths than men.
    (indisputable)
  • 2. Woman live longer than men. (indisputable)
  • Level 2 Evidence (if not Level 1)
  • Live longer if you take baths.

56
Conclusion
  • Flormans Theory 612 is at least as valid as
    most of the other stuff I just said.
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