Title: Severe Head Injury: Review and update And challenging the concept of best available data
1Severe Head Injury Review and update(And
challenging the concept of best available data)
- Jeffrey Florman, MD
- American College of Surgeons
- 2009
2Blah blah
- Lots of head injury
- Lots of ill people
3Severe Head Injury
4Outcome
- For severe CHI (GCSlt8)
- 36 mortality
- Quality of life (GCSlt8)
- Vegetative - 5
- Severe disability - 16
- Moderate disability - 16
- Good - 27
5Patterns 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
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8 9Herniation
10Surgery
11Surgery
- Decompression
- Removing hematoma
- Removing injured brain
- Removing Bone/Foreign Bodies
- Fracture Repair
- Repair of Spinal Fluid Leak
12 13 14Non-surgical Management
- Secondary Injury
- Expanding hematomas
- Brain edema/swelling
- Hypoxemia/Ischemia/Shock
- Fever/infection
- Electrolyte imbalance
- Seizures
- Coagulopathy
- Other non-neurologic (DVT, pneumonia)
15Lets talk
- Optimizing care
- Interpreting The Guidelines
- Institutional biases
- ICP/CPP/PBO2
16The 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
17Data Classification
- Class 1 Good quality RCTs
- Class 2 Moderate quality RCTs and good quality
prospective studies - Class 3 Lesser quality trials and case series
18Levels 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
19Blood 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.
20What 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
23Blood 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.
24Blood Pressure and Oxygenation
- Avoid hypotension SBPlt90
- Avoid hypoxia PaO2lt60 or O2Satlt90
- Steakholders to meet and address this
25Prophylactic 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.
26Prophylactic Hypothermia
- Target normothermia (36-38 C)
- Avoid and treat fever
27Infection 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.
28Infection 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.)
29DVT 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).
30DVT 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?)
31Ventilation
- 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.
32Ventilation
- 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
33Anticonvulsants
- 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.
34Anticonvulsants
- 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
35Steroids
- 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.
36Nutrition
- 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.
37Nutrition
- 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
38Indications 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.
39ICP 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
40Cerebral 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.
41Cerebral Perfusion Pressure
- Target CPPgt60
- Treat hypotension
- Target ICPlt20
42Brain 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.
43Brain Oxygen Monitoring and Thresholds
44ICP 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.
45ICP 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 47Seizures
- Generalized
- Focal
- Big spectrum of presentation
- Can explain generalized decline in function ,
increased ICP, and decreased PBO2 without being
clinically overt
48Fluids
- Prefer Normal Saline resuscitation
- PRBC resuscitation as clinically indicated
- Prefer maintenance IVF Normal Saline with 20meq/L
KCl - Avoid neck lines
49Hematology
- 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.
50Head Position
- Nurse with head elevated 30 degrees with neutral
neck position
51Glucose
- Target serum glucose lt130 mg
- Insulin drip per Yale protocol for diabetics or
hyperglycemia - Give glucose for glucose lt60 mg
52Electrolytes
53Levels 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
54Testing 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.
55The 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.
56Conclusion
- Flormans Theory 612 is at least as valid as
most of the other stuff I just said.