Optimizing ED Management of Severe Traumatic Brain Injury: A Diagnosis

1
Optimizing ED Management of Severe Traumatic
Brain InjuryA Diagnosis Treatment Protocol
2
Scott Weingart, MDAssistant ProfessorDirector
of ED Critical CareElmhurst Hospital
CenterMount Sinai School of MedicineNew York, NY
3
(No Transcript)
4
Objectives

• 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

5
A Clinical Case
6
(No Transcript)
7
(No Transcript)
8
Suspected TBI
from trauma.org imagebank
9
Assess the GCS and Pupillary Response
TBI Procedure
10
(No Transcript)
11
Maintain 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
13
Maintain Sat gt95
TBI Procedure
14
Intubate if the GCSlt9 or you suspect the patient
may decompensate
TBI Procedure
15
Neuroprotective Intubation

• Pretreatment Meds
• Lidocaine
• Fentanyl
• Defasiculating Dose Paralytic
• MAP Stable Dose of Sedative
• Paralytic
• Skilled Intubater

16
Avoid Prophylactic HyperventilationKeep CO2
between 35-38
TBI Procedure
17
If pt is showing signs of impending herniation,
we may hyperventilate to 30 for a brief period of
time
Hyperventilation
18
Signs of Increasing ICP

• Unilateral or bilateral unreactive, dilated pupil
• Extensor posturing (decerebrate)
• A sharp decline in GCS

19
Mannitol1.2-1.4 g / kg
TBI Procedure
20
Confirmed TBI
21
Continue to Maintain MAPContinue to Maintain
SatsContinue to Maintain CO2
TBI Procedure
22
Introduce the patient to a Neurosurgeon
TBI Procedure
23
Monitor ETCO2
TBI Procedure
24
(No Transcript)
25
(No Transcript)
26
Keep PaCO2between 35-38Treat EtCO2 gt35
ETCO2
27
Push Na to 150Never lt 140
TBI Procedure
28
Na in Resus Fluids
Na Cl mOsm/L
NS 154 154 308
LR 130 109 273
29
Head of the Bed to 45
TBI Procedure
30
Temp lt100 F
TBI Procedure
31
Serum Osm lt 320
TBI Procedure
32
Monitor Urine OutputKeep Fluid Balance
TBI Procedure
33
Administer Adequate Sedation Pain Control
TBI Procedure
34
Early AppropriateICP Monitoring
TBI Procedure
35
ICP Monitor Indications

• GCS (3-8) with abnormal head CTs
• GCS (3-8) with normal CTs and two of the
  following
• SBPlt90
• Posturing
• Agegt40

36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
Blaivas M et al. Elevated intracranial pressure
detected by bedside emergency ultrasonography of
the optic nerve sheath. Acad Emerg Med. 2003
Apr10(4)376-81.
40
(No Transcript)
41
CPPMAP ICPKeep ICP lt 20Keep CPP gt 60
ICP Monitoring
42
Treat ? ICP
TBI Procedure
43
Mannitol Boluses1 g / kg over 10
minutesReplace all Urinary Output
ICP Treatment
44
Hypertonic Saline250 cc 3 over 10 minutes
ICP Treatment
45
Treat ? CPP
TBI Procedure
46
FluidsBloodInotropesPressors
CPP Treatment
47
Dilantin Load20 mg/kg over 1 hour
TBI Procedure
48
Admit to a NeuroCriticalCare Bed
TBI Procedure
49
Patient 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

50
Further Reading

• Guidelines for the Management and Prognosis of
  Severe Traumatic Brain Injury. http//www.braintra
  uma.org
• International Trauma Forum. http//www.trauma.org

51
Questions?? www.ferne.orgferne_at_ferne.orgScot
t Weingart, MDgatsby_at_eudoramail.com817.977.3384
Ferne_2006_aaem_sa_weingart_bic_spine.ppt