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Guidelines for the Management of Severe Traumatic Brain Injury

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Title: TBI Guidelines Lecture Subject: Guidelines for the Management of Severe Head Injury Author: Brain Trauma Foundation Last modified by: Martin Strzalka – PowerPoint PPT presentation

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Title: Guidelines for the Management of Severe Traumatic Brain Injury


1
Guidelines for the Management of Severe Traumatic
Brain Injury
  • A joint initiative of
  • The Brain Trauma Foundation
  • The American Association of Neurological Surgeons
  • The Joint Section on Neurotrauma and Critical Care

2

3
TBI - Epidemiology
  • 60,000 ANNUAL TOTAL TBI DEATHS
  • 44,000 OCCUR AT SCENE OR IN E.R.
  • 16,000 OCCUR AFTERWARDS
  • Challenge is to reduce mortality and improve
    outcome.

lower limit estimate Sosin et al. JAMA 1995,
2731778-1780
4
Secondary Injury
  • In the past two decades, medical research has
    demonstrated that all brain damage does not occur
    at the moment of impact, but evolves over the
    ensuing hours and days. This is referred to as
    secondary injury.
  • The injured brain is extremely vulnerable to
    hypotension, hypoxia, and increased intracranial
    pressure which are causes of secondary injury.

5
  • Survey of 219 hospital intensive care units in 45
    states that treated patients with severe head
    injury.
  • Centers
  • Routine ICP monitoring (more in high volume
    centers) 28
  • Hyperventilation and osmotic diuretics routinely
    used 83
  • Aiming for PaCO2 lt 25 mm Hg 29
  • Corticosteroids use more than half the time
    64

Crit Care Med 23 560-567, 1995
6
Findings
  • ICP monitoring used infrequently
  • Severe hyperventilation
  • Use of steroids currently not indicated
  • Wide variability in practice

7
Significant Reductions in Mortality and Morbidity
  • Rapid transport to a trauma care facility
  • Prompt resuscitation
  • CT scanning
  • Prompt evacuation of significant intracranial
    hematomas
  • ICP monitoring and treatment

8
Guidelines for Management of Severe TBI
  • Objectives
  • STATE and DISSEMINATE the current
    scientific evidence for the OPTIMAL management of
    TBI.
  • Highlight issues for further RESEARCH
    and CLINICAL TRIALS.
  • Improve OUTCOME.

9
Guidelines for the Management of Severe Traumatic
Brain Injury
  • Authors
  • Ross Bullock Raj Narayan
  • Randall Chesnut David Newell
  • Guy Clifton Lawrence Pitts
  • Jamshid Ghajar Michael Rosner
  • Donald Marion Beverly Walters
  • Jack Wilberger

10
History
  • 11 authors and 14 topics
  • 3 years of meetings
  • Over 3000 articles reviewed
  • 1st edition completed in 1995
  • 2nd edition completed in 1999

Funded and supported by the Brain Trauma
Foundation (BTF)
11
Advisory Committee
  • Mark Dearden, M.D.
  • Robert Florin, M.D.
  • Andrew Jagoda, M.D.
  • James P. Kelly, M.D.
  • Andrew Maas, M.D.
  • Anthony Marmarou, Ph.D.
  • J. Douglas Miller, M.D.

12
Advisory Committee
  • Peter C. Quinn
  • Jay Rosenberg, M.D.
  • Franco Servadei, M.D.
  • Nino Stocchetti, M.D.
  • Graham Teasdale, M.D.
  • Andreas Unterberg, M.D.
  • Hans von Holst, M.D.
  • Alex Valadka, M.D.

13
Topics
  • Trauma Systems
  • Initial Management
  • Resuscitation of Blood Pressure and Oxygenation
  • Indications for ICP Monitoring
  • ICP Treatment Threshold
  • ICP Monitoring Technology
  • Cerebral Perfusion Pressure

14
Topics
  • Hyperventilation
  • Mannitol
  • Barbiturates
  • Steroids
  • ICP Treatment Algorithm
  • Nutrition
  • Antiseizure Prophalyxis

15
Topic Chapter Format
  • I. Recommendations
  • A. Standards
  • B. Guidelines
  • C. Options
  • II. Overview
  • III. Process
  • IV. Scientific Foundation
  • V. Summary
  • VI. Key Issues for Future Investigation
  • VII. Evidentiary Table
  • VIII. References

16
Guidelines for the Management of Severe Traumatic
Brain Injury
  • Topics list
  • Electronic literature search (Medline)
  • All relevant articles
  • Screened for scientific and statistical validity
  • Classified according to a three point scale
  • Class I
  • Class II
  • Class III

17
Guidelines for the Management of Severe Traumatic
Brain Injury
  • Class I
  • Prospective, Randomized, Controlled Trials
  • Class II
  • Non-Randomized, Prospective Controlled Trials
  • Observational Studies
  • Class III
  • Case Series
  • Case Reports
  • Expert Opinion

18
Guidelines for the Management of Severe Traumatic
Brain Injury
  • Standards
  • Class I Evidence
  • Guidelines
  • Class II Evidence
  • Options
  • Class III Evidence

19
Guidelines for the Management of Severe Traumatic
Brain Injury
  • Standards
  • Represent principles that reflect a high
    degree of clinical certainty
  • Guidelines
  • Represent principles that reflect a moderate
    degree of clinical certainty
  • Options
  • Represent principles for which there is unclear
    clinical certainty

20
Guidelines for the Management of Severe Traumatic
Brain Injury
  • The Spirit is Willing but the Data is Weak
  • State only what the literature supports
  • First step toward standardizing head injury
    management
  • Mandate for Class I studies

21
Trauma Systems
  • Guideline
  • All regions in the United States should have an
    organized trauma care system

22
  • 1643 trauma patients treated at seven trauma
    centers with differing annual volumes of trauma
    patients.
  • Patients taken to a low volume trauma center
    had a 30 greater chance of dying.

J. Trauma 30 1066-1076, 1990
23
Resuscitation of Blood Pressure Oxygenation
  • Guideline
  • Hypotension (SBP lt 90 mm Hg) or hypoxia (apnea of
    cyanosis in the field or a PaO2 lt 60 mm Hg) must
    be scrupulously avoided, if possible,
    or corrected immediately.
  • Option
  • The mean arterial pressure should be
    maintained above 90 mm Hg throughout the
    patients course.

24
  • Prospective prehospital and E.R. study of 717
    severe head injury patients in the Traumatic Coma
    Data Bank.
  • Hypotension (SBP lt 90 mm Hg) occurred in 35 of
    patients and was associated with a two fold
    increase in mortality.

J. Trauma 34216-222, 1993
25
Initial Management
  • Option
  • The first priority for the head injured patient
    is complete and rapid physiologic
    resuscitation. No specific treatment should be
    directed at intracranial hypertension in the
    absence of signs of transtentorial herniation or
    progressive neurologic deterioration not
    attributable to extracranial explanations.

26
  • CBF measured in 35 severely head injured patients
    with Xe-CT at, on average, 3 hours after injury.
  • Global or regional ischemia (CBF lt 18 ml/100
    gm/min) observed in 31 patients.
  • Global ischemia was measured in 57 of patients
    with diffuse swelling.

J. Neurosurg 77 360-368, 1992
27
Indications for ICP Monitoring
  • Guideline
  • ICP monitoring is appropriate in severe head
    injury patients with an abnormal CT, or a normal
    CT scan if 2 or more of the following are noted
    on admission
  • SBP lt 90 mm Hg
  • Age gt 40 years
  • Uni-/Bilateral motor posturing

28
  • 207 severely head injured patients who had ICP
    monitoring and head CT scans
  • Patients with a normal head CT had a 13 chance
    of ICP gt 20 mm Hg
  • Risk of intracranial hypertension (with normal
    CT) increased to 60 if two or more of the
    following were noted
  • 1) Age over 40 years
  • 2) SBP lt 90 mm Hg
  • 3) motor posturing

J. Neurosurg 56 650-659, 1982
29
ICP Monitoring Technology
  • Recommendation
  • In the current state of technology, the
    ventricular catheter connected to an external
    strain gauge is the most accurate, low cost, and
    reliable method of monitoring ICP. It also
    allows therapeutic CSF drainage.
  • ICP transduction via fiberoptic or strain gauge
    devices placed in ventricular catheters provide
    similar benefits but at a higher cost.

30
CT Scan

31
ICP Treatment Threshold
  • Guideline
  • ICP treatment should be initiated at an upper
    threshold of 20 - 25 mm Hg.

32
  • The ICP threshold that was most predictive of 6
    month outcome was analyzed in 428 severely head
    injured patients.
  • The proportion of hourly ICP reading greater than
    20 mm Hg was a significant independent
    determinant of outcome.

J. Neurosurg 75S59-S66, 1991
33
Cerebral Perfusion Pressure
  • Option
  • Cerebral Perfusion Pressure should be maintained
    at a minimum of 70 mm Hg.

34
  • 158 patients with GCS lt 7 managed according to
    a CPP protocol
  • Maintain euvolemia (CVP 8-10 mm Hg)
  • Ventriculostomy CSF drainage at 15 mm Hg
  • Systemic vasopressors to maintain CPP at least 70
    mm Hg
  • Hyperventilation, barbiturates, hypothermia not
    used.
  • Mortality 29 and 2 vegetative for entire group.
    Favorable outcome in GCS 3 of 35 ranging up to
    75 for GCS 7.

J. Neurosurg 83 949-962, 1992
35
Hyperventilation
  • Standard
  • In the absence of increased intracranial pressure
    (ICP), chronic prolonged hyperventilation therapy
    (PaCO2 of 25 mm Hg or less) should be avoided
    after severe traumatic brain injury (TBI).
  • Guideline
  • The use of prophylactic hyperventilation (PaCO2 lt
    35 mm Hg) therapy during the first 24 hours after
    severe TBI should be avoided because it can
    compromise cerebral perfusion during a time when
    cerebral blood flow (CBF) is reduced.
  • Option
  • Hyperventilation therapy may be necessary for
    brief periods when there is acute neurologic
    deterioration, or for longer periods if there is
    intracranial hypertension refractory to sedation,
    paralysis, cerebrospinal fluid (CSF) drainage,
    and osmotic diuretics.

36
J. Neurosurg 75731-739, 1991
  • A randomized prospective clinical trial in 113
    patients to study the effect of hyperventilation
    (PaCo2 25 mm Hg) compared to normal ventilation
    (PaCo2 35 mm Hg) in patients with similar severe
    head injury.
  • Significantly fewer patients made a good recovery
    at 3 and 6 months post injury who had a GCS 6 or
    7 on admission.

PROPHYLACTIC USE OF SUSTAINED HYPERVENTILATION
FOR A PERIOD OF 5 DAYS RETARDS RECOVERY
FROM SEVERE HEAD INJURY.
37
Mannitol
  • Guideline
  • Mannitol is effective for control of raised ICP
    after severe head injury.
  • Option
  • Effective doses range from 0.25 - 1.0 gm/kg body
    weight.

38
Mannitol
  • Option
  • The indications for the use of mannitol prior to
    ICP monitoring are signs of transtentorial
    herniation or progressive neurological
    deterioration not attributable to systemic
    pathology.
  • However, hypovolemia should be avoided by fluid
    replacement.

39
Barbiturates
  • Guideline
  • High-dose barbiturate therapy may be
    considered in hemodynamically stable salvagable
    severe head injury patients with intracranial
    hypertension refractory to maximal medical and
    surgical ICP lowering therapy.

40
  • A prospective trial of 73 patients with severe
    head injury and medically refractory intracranial
    hypertension, randomized to receive either a
    regimen including high-dose pentobarbital or
    similar regiment without pentobarbital.
  • Refractory intracranial hypertension occurred in
    only 12 of the original severe head injury group
    (925 Patients).
  • The chance of survival for those patients whose
    ICP decreased(ICP lt 20 mm Hg) with barbiturate
    treatment was 92 compared to 17 when it did not.

J. Neurosurg 6915-23, 1988
41
Steroids
  • Standard
  • The use of steroids is not recommended for
    improving outcome or reducing intracranial
    pressure in patients with severe head injury.

42
  • Prospective randomized trial in 300 patients
    receiving dexamethasone (total IV dose within 51
    hours of injury 2.3 grams IV) versus placebo.
  • No difference in outcome examined serially within
    one year after treatment.

Zentralbl Neurochir 55135-143, 1994
43
Antiseizure Prophylaxis
  • Standard
  • Prophylactic use of phenytoin, carbamazepine,
    phenobarbital or valproate is not recommended for
    preventing late post-traumatic seizures.

44
  • 404 post traumatic head injury patients (GCS 3-10
    and abnormal head CT) randomized to treatment
    with phenytoin or placebo for one year with a two
    year follow up.
  • In the first week after injury 4 of the patients
    receiving phenytoin had seizures compared to 14
    taking placebo.
  • After the first week there was no significant
    difference between the rate of seizures in the
    two groups.

N. Engl. J. Med 323497-502, 1990
45
Nutrition
  • Guideline
  • Replacement of 140 of Resting Metabolic
    Expenditure in non-paralyzed patients and 100
    Resting Metabolic Expenditure in paralyzed
    patients using enteral or parenteral formulas
    containing at least 15 of calories as protein by
    the seventh day after injury.

46
  • Prospective trial in 38 patients randomly
    assigned to receive total parenteral nutrition
    (TPN) or standard enteral nutrition (SEN).
  • The TPN group got full nutritional support by 7
    days whereas the SEN group did not. There were
    significantly more deaths in the group that did
    not receive full caloric replacement by the 7th
    day after injury.

J. Neurosurg 58907-912, 1983
47
ICP Treatment Algorithm
  • Option
  • An algorithm, developed by consensus, is
    presented. It should be viewed as expert
    opinion and used as a framework which may be
    useful in guiding an approach to treating
    intracranial hypertension.

48
Critical Pathway for Treatment of Intracranial
Hypertension in the Severe Head Injury Patient
(Treatment Option)
Insert ICP Monitor
Maintain CPP ? 70 mmHg
NO
YES
Intracranial Hypertension?
Ventricular Drainage (if available)
Intracranial Hypertension?
YES
NO
May Repeat Mannitol if Serum Osmolarity lt 320
mOsm/L Pt euvolemic
Carefully Withdraw ICP Treatment
Consider Repeating CT Scan
Mannitol (0.25 - 1.0 g/kg IV)
Intracranial Hypertension?
YES
NO
Hyperventilation to PaCO2 30 - 35 mmHg
Intracranial Hypertension?
YES
NO
Other Second Tier Therapies
  • Hyperventilation to PaCO2 lt 30 mmHg
  • Monitoring SjO2, AVDO2, and/orCBF Recommended

High Dose Barbiturate therapy
Second Tier Therapy
Threshold of 20-25 mmHg may be used. Other
values may be substituted in individual
conditions.
49
Guidelines for the Management of Severe
Traumatic Brain Injury
  • To place an order call Brain Trauma Foundation _at_
    1-212-772-0608 fax 1-212-772-0357 www.
    braintrauma.org

50
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