btf guidelines for tbi maj ajay

7/29/2019 BTF Guidelines for TBI Maj Ajay

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https://www.braintrauma.org/pdf/protected/Guidelines_Manage

ment_2007w_bookmarks.pdf
https://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdfhttps://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdfhttps://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdfhttps://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdfhttps://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdfhttps://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdf


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BTF

A joint project of the Brain Trauma Foundation

American Association of Neurological Surgeons(AANS)

Congress of Neurological Surgeons(CNS)

AANS/CNS Joint Section on Neurotrauma and CriticalCare


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TBI(Traumatic Brain

Injury)Incidence 56430/100,000

Male: female = 3:2

60% occur in 2040 yr age

High mortality and morbidity

Majority of deaths occur in the first 72 hrs

Commonest cause is road traffic accidents


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Introduction Major cause of disability, death and economic cost to

our society.

Damage from TBI not only at the time of impact butevolves over a time of hours and days.

Reduction in mortality from 50%--35%--25%

subsequent to the use of Evidence Based Protocols thatemphasize monitoring and maintaining adequatecerebral perfusion


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BTF Guidelines for management TBI

1st Edition: 1995

2nd

Edition: 2000

3rd Edition: 2007

6 new chapter

Standard Level I

Guidelines Level II

Options Level III


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Topic

Blood Pressure andOxygen

Hyperosmolar Therapy

ProphylacticHypothermia

Infection Prophylaxix

DVT Prophylaxix

Indications for ICPmonitoring

ICP MonitoringTtechnology

ICP Thresholds Brain Oxygen monitoring

and Threshold

Anaesthetics, Analgesics, andSedatives

Nutrition

Antiseizure Prophylaxis

Hyperventilation Steroids


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Levels of Recommendations Level I : Recommendations are based on the

strongest evidence, represent principles of

patient management that reflect a high degree

of clinical certainty.

Level II : Recommendations reflect a moderate

degree of clinical certainty.

Level III : Recommendations for which the

degree of clinical certainty is not established


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Blood Pressure and Oxygen

Level I: Insufficient Data

Level II: BP should be monitored and Hypotension


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Scientific Foundation

(data collected from TCDB)

Hypoxemia occurred in 22.4% of severe TBI mortality andmorbidity

In non-Hypoxemic patient mortality was 14.3% with a 4.8%rate of severe disability

Patient with O2 saturation


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A single episode of Hypotension (SBP


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Key Issues Ethical : Manipulative investigation

Level of hypoxia/hypotension that correlates with pooroutcome

Treatment threshold

Optimum resuscitation protocols for hypoxia andhypertension

Specification of target values


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Hyperosmolar Therapy


Level II: Mannitol 0.25-1gm/kg BW effective for raisedICT( SBP


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Possible MOA of Mannitol

Immediate

Plasma expansion

hematocrit

Blood viscosity

deformability of erythrocyte

CBF and O2 delivery

Osmotic

Delayed 15-30min

Persists for 90min-6hrs

Risks: Arterial hypotension

SepsisNephrotoxicity


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Hypertonic Saline Osmotic mobilization of water across BBB

Cerebral water content

HS as a bolus infusion may be an effective adjuvent oralternative to mannitol

However current evidence is not strong enough to makerecommendation


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Key Issues RCT to determine relative benefit of HSVs mannitol

Optimal administration and concentration of HS

Validation of use single high dose mannitol

Efficacy of prolonged hypertonic therapy for raisedICT, especially in relation to outcome.


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Prophylactic Hypothermia


Level II: Insufficient Data

Level III: Not significantly associated with mortalityVs normothermic, however some findings suggest that

a greater mortality risk if target temp maintained for>48 hrs


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Evidence from 6 moderate quality RCT

Not clearly demonstrate hypothermia with significantreduction in mortality.

Hypothermia may have higher chances of reducingmortality and better GOS(Glasgow Outcome Scale) scoreof 4 or 5 if cooling maintained for >48 hrs.


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Key Issues Inadequate or poorly described randomization

Inability to rule out confounding of treatment effects

No blinding of outcome assessors

Inadequate management of missing outcome data

Improvement : Independent event monitoring committees

: Larger sample size/Multiple centre

: Increase standardization / Control group


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Infection Prophylaxis Level I: Insufficient Data

Level II: Periprocedural antibiotics (Intubation) toreduce incidence of Pneumonia

Level III: Routine Ventricular catheter exchange or

prophylactic antibiotic use for its placement is notrecommended.


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Ventriculostomies and other ICP monitors should beplaced under sterile condition to close drainage systemsminimising manipulation and flushing

No support for use of prolonged antibiotics for systemicprophylaxis in intubated TBI patient

A single study(Sirvent et al) supports the use of a shortcourse of antibiotic at the time of intubation the riskof pneumonia


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Key Issues

Lack of RCTs with sufficient number of TBI

Trials including those with antibiotic impregnatedcatheters, would be both ethical and useful


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DVT Prophylaxis Level I: Insufficient Data


Level III: Graduated Compression stockings or intermittentpneumatic compression(IPC) unless lower

extremity injuries (till ambulation): LMWH/ low dose UH should be used incombination with mechanical prophylaxis

( risk of expansion of ICH)


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Risk of DVT in absence of DVT prophylaxis 20% aftersevere TBI

Any decision must weigh efficacy against harm(Intracranial/systemic bleeding)

No reliable data for pharmacological prophylaxis and

medication choice or optimal dosing regimen basedon current evidence


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Key Issues

An RCT of mechanical prophylaxisVswith addition ofpharmacological prophylaxis in severe TBI is needed

Specifically address the issue ofWHEN, WHAT andHOW MUCH

Comparison of risk in specific traumatic intracraniallesion(eg. ContusionVs SDHVs SAH etc.)

Vena Cava Filters


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Indications of

ICP monitoring Level I: Insufficient Data

Level II: ICP should be monitored in all severe TBI(GCS

3-8) and an abnormal CT

Level III: Patient with severe TBI with normal CT with2 or more of followig features present

: Age >40 years: Uni/Bilateral motor posturing

: Systolic BP


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ICP data useful in predicting outcome and guidingtherapy

There is an improvement in outcomes in those patientswho respond to ICP lowering therapy

Treating elevated ICP without monitoring can bedeleterious and result in a poor outcome


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Key Issues

RCT of ICP monitoring with or without treatment

Further studies on sequential normal CT in severe TBIpatients and the incidence of ICH and evolving lesionswould be useful to identify a group that may notrequire ICP monitoring and treatment.


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ICP Monitoring TechnologyAccurate, Reliable, Cost effective and cause

minimum patient morbidity.

AAMI (Association of the Advancement of MedicalInstrumentation) standard device should havefollowing specifications:

> Pressure range 0-100 mm Hg

> Accuracy + 2 mm Hg in range of 2-20 mm Hg> Maximum error 10% in range of 20-100mm Hg


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Ranking of ICP Monitoring Technology

1. Intraventricular devices: fluid-coupled catheter withexternal strain guage

2. Intraventricular devices: micro strain gauge or fibroptic

3. Parenchmal pressure transducer devices

4. Subdural devices

5. Subarachnoid fluid coupled devices

6. Epidural devices


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Key Issues Specification for ICP devices should be reviewed in the

context of what data is useful in management ofpatient that receive ICP monitoring

Research about parenchymal monitoring near acontusion site provide ICP data that improve ICPmanagement and outcome as compared to other sites

To develop multiparametric ICP devices that canprovide measurement of Ventricular CSF, parenchymalICP and other advanced monitoring parameters


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ICP Threshold


Level II: Treatment should be started with ICPthresholds > 20 mm Hg

Level III:A combination of ICP values, and clinical

and brain CT findings should be used to determinetreatment


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Key Issue Identify more concrete treatment thresholds for ICP

: To develop a method to estimate Herniation Pressure

: To determine the critical values for other parameters


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Cerebral Perfusion

Threshold Level I: Insufficient Data

Level II:Aggressive attemps to maintain CPP >70 mmHg with f luids and pressors should be avoided( Risk ofARDS)

Level III: CPP


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Critical threshold for ischemia generally lies in the

realm of 50-60 mm Hg

General threshold in the realm of 60 mm Hg

fine tuning in patients not readily responding to basictreatment or with systemic contraindication toincrease CPP manipulation

Routinely using pressors and volume expansion tomaintain CPP >70 mm Hg is not supported (systemiccomplications)


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Key Issues Minimally invasive, efficient, and accurate methods of

determining and following the relationship betweenCPP and autoregulation and between CPP and Ischemia

in individual patient

RCT for influence on outcome of basing optimal CPPon ischemia monitoring or on the quantitative indices

of pressure autoregulation


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Brain Oxygen Monitoring

and Thresholds Level I: Insufficient Data


Level III:Jugular venous saturation


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Patients with multiple desaturation episode had 46-

71% mortalityVs patients without desaturation (18%)

Arterio-Jugular difference of O2 content (AJDO2) ameasurement of O2 extraction by tissue with high

value (4.3 vol %) was associated with better prognosis

Brain tissue O2 saturation (PbtO2) 30 min associated with high mortality


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Key Issues Future investigation need to explore what specific

therapeutic strategies can improve the outcome andprevent these threshold (SjO2, AJDO2 or PbtO2) frombeing crossed.

For SjO2 monitors may require technologicalimprovements

Issues about probe placement w/r/t location of injury


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Anaesthetics, Analgesics

and Sedatives Level I: Insufficient Data

Level II : Prophylactic Barbiturates to induce burst

suppression EEG not recommended

: High dose Barbiturates recommended tocontrol elevated ICP refractory to maximum

med/surg treatment

: Propofol recommended for control of ICP,

no long term improvement in mortality

outcome


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Analgesics and Sedatives are common managementstrategy for ICP control, but no evidence to supporttheir efficacy in this regard and no positive effect onoutcome

Attention must be paid to potential undesirable side

effects that might contribute to secondary injury


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Key Issues To identify subsets of patients who might respond

favorably to analgesic-sedative and/or barbituratetreatment

To identify alternative agents, drug combinations, anddosing regimens

Research about novel sedative-anaestheticDexmedetomidine


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Nutrition


Level II : Patients should be fed to attain full caloricreplacement by day 7 post-injury


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Starved TBI patient lose sufficient nitrogen to reduce

weight by 15% per week

100-140% replacement of Resting Metabolism Expenditurewith 15-20% nitrogen calories reduces nitrogen loss

It is not established that any method of feeding is betterthan another

Full nutrition replacement be instituted by day 7 post-injury


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Key Issues Studies to determine if specific nutritional formulations

and addition of vitamins and other supplements canimprove outcome

Timing of feeding, Rate of achievement of target caloricintake and method of delivery


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Antiseizure Prophylaxis Level I: Insufficient Data

Level II : Prophylactic use of Phenytoin or Valproate isnot recommended for preventing lateposttraumatic seizures(PTS)

: Indicated to decrease the incidence of early

PTS (within 7 days of injury), However earlyPTS is not associated with worse outcome


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Majority of studies do not support the use of prophylacticanticonvulsants for prevention of late PTS

Routine use later than 1 week not recommended

For late PTS patients should be approached as new onsetseizures

Phenytoin shown to reduce early PTS, Valproate hascomparable efficacy to Phenytoin but may be associatedwith higher mortality


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Key IssuesAdditional studies about effect on outcome after

reduction in early PTS

Study should utilize continuous EEG monitoring toidentify seizures

Study about neuroprotective agents eg. MgSO4 and

other NMDA receptor antagonists


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Hyperventilation Level I: Insufficient Data

Level II : Prophylactic hyperventilation (PaCO2 of 25

mm Hg or less) is not recommended

Level III : Recommended as a temporizing measurefor reduction of elevated ICP

:Avoided during first 24 hrs when CBF isoften critically reduced

: If hyperventilation is used, SjO2 or PbtO2

measurement are recommended


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Hyperventilation reduces ICP by causing cerebral

vasoconstriction, and so the CBF

Because of vasoconstriction, risk of ischemia withaggressive hyperventilation

Poorer outcome at 3-6 months when prophylactichyperventilation was used compared to when not used


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Key Issues

Further RCT need to be conducted for

: How does short term hyperventilation affect outcome

: Effect of moderate hyperventilation in specific subgroup

: Critical levels of PaCO2/CBF and outcome


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Steroids

Level I : Not recommended for improving outcome orreducing ICP

: High dose methylprednisolone is associated

with increased mortality and is contraindicated


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Trials in TBI with different steroids (syntheticglucocorticoid, triancinolone, 21-aminosteroid tirilazard,dexamethasone, methylprednisolone) None has indicatedan overall beneficial effect on outcome

One trial was halted when interim analysis showedincreased mortality


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Key Issues

If new compounds with different mechanism ofactions are discovered, further study may be justified


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Hyperventilation

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btf guidelines for tbi maj ajay

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