severe traumatic brain injury francesco della corte, md associate professor university a. avogadro,...

Severe Traumatic Brain InjurySevere Traumatic Brain Injury

Francesco Della Corte, MDFrancesco Della Corte, MD

Associate Professor Associate Professor University A. Avogadro, School of MedicineUniversity A. Avogadro, School of Medicine

Novara, ItalyNovara, Italy

•On the site of accident 3.30 pm

•Male 34 yrs old•GCS 6 (V1; E1; M4)•Pupil size unequal (left > right - not reactive)•Gasping•Abdominal distension•Fracture of the left leg•RSI, ETI, sedation and volemic infusion

•MVA •High speed •Deformity on the left side


•At the ED at 4.30At the ED at 4.30

•GCS 6 (V1; E1; M4)GCS 6 (V1; E1; M4)

•Pupil size unequal (left > right - not reactive)

•Left eyelid contusion and bulb rotated left and downwardLeft eyelid contusion and bulb rotated left and downward

•Flexion at the right arm to painFlexion at the right arm to pain

•AP 73/43 mmHg; HR 135 bpmAP 73/43 mmHg; HR 135 bpm

•SpO2 100%; Hb 4.5 g/dlSpO2 100%; Hb 4.5 g/dl

•Abdominal US: positiveAbdominal US: positive

•Chest Xray (multiple left chest rib fractures)Chest Xray (multiple left chest rib fractures)•Transported immediately in the OR for splenectomyTransported immediately in the OR for splenectomy


E.R.E.R.E.R.E.R.

O.R.O.R.O.R.O.R.

ICUICUICUICU

RescueRescue/transport/transportRescueRescue/transport/transport

DiagnosisDiagnosisDiagnosisDiagnosis

Key QuestionsKey Questions

• Priorities in the treatment of severe head injuries: Priorities in the treatment of severe head injuries:

• the role and prevention of cerebral ischemiathe role and prevention of cerebral ischemia

• The ABCsThe ABCs

• Is preH ETI an absolute priority in the managementIs preH ETI an absolute priority in the managementof the STBI?of the STBI?

• When to hyperventilate or not to hyperventilate?When to hyperventilate or not to hyperventilate?• What is the gold target for BP?What is the gold target for BP?

• What about sedation in severe HI?What about sedation in severe HI?

• How much to rely on the first CT for further evolution and prognosis?How much to rely on the first CT for further evolution and prognosis?

•Out of the OR 5.45 pm

•Sedation and analgesia Sedation and analgesia

•(propofol 2.5 mg/Kg/h & remifentanyl 0.05 mcg/kg/min)(propofol 2.5 mg/Kg/h & remifentanyl 0.05 mcg/kg/min)

•GCS 6 (V1; E1; M4) + persisting pupils unequalGCS 6 (V1; E1; M4) + persisting pupils unequal

•BP 125/76 mmHg; HR 95 bpmBP 125/76 mmHg; HR 95 bpm

•SpO2 100%; Hb 9.5 g/dlSpO2 100%; Hb 9.5 g/dl

•CT scanCT scan

The Case Cont’dThe Case Cont’d

CT scan


Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries:

• the role and prevention of cerebral ischemiathe role and prevention of cerebral ischemia

•Prognosis of HI is strictly related to:Prognosis of HI is strictly related to:

•degreedegree

•duration of cerebral ischemiaduration of cerebral ischemia

More than 90% of authopsies in HI showed ischemic More than 90% of authopsies in HI showed ischemic lesions of different severitylesions of different severity

Graham D.I., Adams J.H. Ischemic brain damage in fatal head injuries. Lancet 1:265-266, 1971


Postraumatic cerebral ischemia

Intracranial hypertensionArterial hypotension

Brain swelling or

Cerebral edema

Focal compression due to

intracerebral or extrassial

hematomas

Vasospasm


the role and prevention of cerebral ischemiathe role and prevention of cerebral ischemia


Martin NA, Patwardhan RV, et al: Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm.J Neurosurg 87: 9-19, 1997

Day

0 1 2 3 4 5 6 7 8 9 10 11 12 13

CBFml/100g/min

CBFml/100g/min

25

30

40

20

35

. .... .

.

.

..

I II IIIPhase

Time course and CBF in head injuryTime course and CBF in head injury45



Pbp OPbp O22

Van den Brink, Neurosurgery 46; 868-878, 2000



0

2

4

6

8

10

12

14

16

Day 1 Day 2 Day 3 Day 4

mM in CSF

GlutamateGlutamate Days after TBI

Yamamoto: Acta Neurochir S75: 31-34, 1999Yamamoto: Acta Neurochir S75: 31-34, 1999

Elevation of microdialysate lactate concentration after Elevation of microdialysate lactate concentration after head injuryhead injury

Goodman JC, Crit care med 27; 1965-1973, 1999

Fig. 3 up

1day 2 day 3 day 4 day 5 day





• The ABCsThe ABCs

Airway patencyBreathing

CCirculationirculation

DDisabilityisability

EExposurexposure

AAntioxidantsntioxidantsBBarbituratesarbituratesCCalcium antagonistsalcium antagonistsDDexamethasoneexamethasoneEE vitamine vitamine


AAirways patencyirways patency

Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries:the ABCs the ABCs


• Guidelines• Hypoxemia (apnea, cyanosis or arterial hemoglobin O2 saturation <

90%) must be avoid, if possible, or corrected immediately… Hypoxemia should be corrected by administering supplemental oxygen

• Options• The AW should be secured in patients with GCS < 9, with inability

to maintain an adequate airway or hypoxemia not corrected by supplemental O2.

• Endotracheal intubation, if available, is the most effective procedure to maintain the airway

Airway patencyAirway patencyABCsABCs

BTF – AANS - 2000 Francesco Della Corte, MDFrancesco Della Corte, MD

Early endotracheal intubation

Indications:

• Airway obstruction in any case• Maintainance of an adequate oxygenation and ventilation• Prevention of hyper and hypocapnia• Protection of airways obstruction• Prevention of neurological deterioration in hostile environments

(transport, radiological procedures)

ABCsABCs

Airway patencyAirway patency


• Orotracheal intubation should be preferred

• Blind nasotracheal intubation is to be avoided:

• In any case a fracture of the basis (and maxillar) is suspected

It needs the patient breaths spontaneously High percentage of failuresIt could give nasal bleeding (obstacle to orotracheal intubation)

• A cervical spine lesion must ever be suspected in a a comatose patient. Treat him/her as having a spine injury

ABCsABCs Airway patencyAirway patency


• Murray JA J Trauma. 2000 Dec;49(6):1065-70. Prehospital intubation in patients with severe head injury.• For patients with severe head injury, prehospital intubation did not

demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results.

• Bochicchio GV J Trauma 2003 Feb; 54(2): 307-11. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. • Prehospital intubation is associated with a significant increase in

morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury.

ABCsABCs

Is preH ETI an absolute priority in the management of the HI?Is preH ETI an absolute priority in the management of the HI?


Brescia 2°, Lecco, Milano Niguarda, Milano Policlinico, Milano San Raffaele, Monza, Pavia 2°, Roma, Sondalo, Varese

Ancona

Bologna Bellaria, Cesena

Genova Galliera

Roma Gemelli

Torino CTO

Treviso, Vicenza

Trieste

Patients1000

1100

1200

1300

G. Citerio, N. Stocchetti, M. Cormio , L. Beretta : Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochirurgica Volume 142 Issue 7 (2000) pp 769-776

1818 CENTERSCENTERS3 months3 months

1818 CENTERSCENTERS3 months3 months

Pre-H intubationPre-H intubation

3 4 5 6 7 8 GCS0

10

20

30

40

50

60

70

80

N

Y


Is preH ETI an absolute priority in the management of the HI?Is preH ETI an absolute priority in the management of the HI?

ABCsABCs

BBreathingreathing




ABCs ABCs

BBUT UT should they beshould they be

hyperventilated or not to hyperventilated?hyperventilated or not to hyperventilated?

All intubated patients All intubated patients mustmust be ventilated be ventilated to obtainto obtain::

• adequate oxygenation (paOadequate oxygenation (paO22 > > 90 mmHg, SaO90 mmHg, SaO22 > > 95%)95%)

• prevention of hyper- or hypocapnia, with PaCOprevention of hyper- or hypocapnia, with PaCO22 at at 35 mmHg35 mmHg

Recommendations for the treatment of adults with severe head trauma (Part I) – Min. Anest. 5,1999

186 pts (Bouma 1991) (Robertson 1992; Jaggi 1990; Marion 1991, Martin 1997)2020

2525

3030

3535

4040

< 6

< 6

6-1

26

-12

12

-18

12

-18

18

-24

18

-24

24

-30

24

-30

30

-36

30

-36

36

-42

36

-42

42

-48

42

-48

> 4

8>

48

CBFCBFml/100 g/minml/100 g/min

Hours post injury


When to hyperventilate or not to hyperventilate?When to hyperventilate or not to hyperventilate?


Brain Trauma Foundation, et al:J Neurotrauma, 17:513-520, 2000

Standards: In the absence of increased ICP chronic prolonged hyperventilation (25 mmHg or less) should be avoided

Guidelines: prophylactic hyperventilation (<35 mmHg) during the first 24 hours should be avoided

Options: Hyperventilation may be necessary for brief periods when there is neurologic deterioration, or for longer if there is intracranial hypertension refractory to sedation, paralysis, CSF drainage and osmotic diuretics.

Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries:ABCs ABCs

699 patients699 patients

Mortality Mortality (SHI at time of arrival at ER) = (SHI at time of arrival at ER) = 36.6 %36.6 %

00 1010 2020 3030 4040 5050 6060 7070 8080 9090 100100

Mortality %Mortality %

27 %27 %NeitherNeither

75 %75 %

60 %60 %

33 %33 %HypoxiaHypoxia

HypotensionHypotension

BothBoth

Chesnut RM et al. J trauma 1993; 34:216-222Chesnut RM et al. J trauma 1993; 34:216-222 Francesco Della Corte, MDFrancesco Della Corte, MD

Secondary insults Secondary insults first 24 hrsfirst 24 hrs

0 100 200 300 400 500

58%

11%

14%

18%

None

Hypoxia

Hypotension

Both

Mutually exclusiveMutually exclusive

HypotensionHypotension = SBP = SBP 90 mmHg or 90 mmHg or cyanosis or no peripheral pulse cyanosis or no peripheral pulse HypoxiaHypoxia = SaO = SaO2 2 90 or apnea or 90 or apnea or

cyanosiscyanosis

HypotensionHypotension = SBP = SBP 90 mmHg or 90 mmHg or cyanosis or no peripheral pulse cyanosis or no peripheral pulse HypoxiaHypoxia = SaO = SaO2 2 90 or apnea or 90 or apnea or

cyanosiscyanosis



Secondary insults - GOS 6 monthsSecondary insults - GOS 6 months

0 50 100 150 200 250

Both 51% 18%

Hypotension 54% 26%

Hypoxia 25% 44%

None 19% 52% 1

2

3

4

5

(20.001)

HypotensionHypotension = SBP = SBP 95 mmHg or 95 mmHg or cyanosis or No peripheral pulse cyanosis or No peripheral pulse HypoxiaHypoxia = SaO = SaO2 2 90 or apnea or cyanosis 90 or apnea or cyanosis

HypotensionHypotension = SBP = SBP 95 mmHg or 95 mmHg or cyanosis or No peripheral pulse cyanosis or No peripheral pulse HypoxiaHypoxia = SaO = SaO2 2 90 or apnea or cyanosis 90 or apnea or cyanosis

GOS



Hypotension and Head InjuryHypotension and Head Injury

Manley G,Arch Surg. 2001Manley G,Arch Surg. 2001

p= 0.009p= 0.009



Hypoxemia (<90% arterial hemoglobin oxygen saturation or apnea,

cyanosis or a paO2 < 60 mmHg) Hypotension (<90 mmHg systolic blood pressure)

are significant parameters associated with a poor outcome in patients with STBI in the prehospital setting

Guidelines for Prehospital Management of TBI. BTF, 1999




•CPP should be maintained at greater than 60 mmHg in adults•CPPs of 50 mmHg or lower have been shown to be associated with critical reductions and with increased mortality following severe TBI•No study has found that the incidence of intracranial hypetension, morbidity or mortality is increased by the active maintainance of CPP above 60 mmHg•…. Artificial attempts to maintain CPP above 70 mmHg may be associated with an increase incidence of ARDS

Guidelines for the management of STBI: CPP - BTF – AANS March 14,2003

WWhat is the optimal target for BP?hat is the optimal target for BP?



keep systolic BP > 110 mmHg in adults

to ensure adequate cerebral perfusion pressure

Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries:ABCsABCs



What is the optimal target for BP?What is the optimal target for BP?



The value of 90 mmHg SBP to delineate the threshold for The value of 90 mmHg SBP to delineate the threshold for hypotension has arisen arbitrarirly and is more statistical than ahypotension has arisen arbitrarirly and is more statistical than aphysiologic parameter….. physiologic parameter…..

It may be valuable to maintain MAP considerably above those It may be valuable to maintain MAP considerably above those represented by SBP of 90 mmHg…represented by SBP of 90 mmHg…

Guidelines for Prehospital Management of TBI. BTF, 1999Guidelines for Prehospital Management of TBI. BTF, 1999

Is MAP a better endpoint than systolic BP?Is MAP a better endpoint than systolic BP?




• the role of cerebral ischemiathe role of cerebral ischemia• ABCsABCs

• Is preH ETI an absolute priority in the management of the HI?Is preH ETI an absolute priority in the management of the HI?• To hyperventilate or not to hyperventilate?To hyperventilate or not to hyperventilate?• What is the gold target of BP? What is the gold target of BP?

• What about sedation?What about sedation?• How much to relay on the first CT for further developments?How much to relay on the first CT for further developments?


Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries: What about sedation? What about sedation?

• MMidazolam 0.idazolam 0.11-0.-0.22 mg/kg mg/kg or or• PPropofol 1-2 mg/kg ivropofol 1-2 mg/kg iv (attention to hypotension) (attention to hypotension)

if hypotensive or bleedingif hypotensive or bleedingthiopental 1 mg/kg or midazolam 0.05-0.1 mg/kg;thiopental 1 mg/kg or midazolam 0.05-0.1 mg/kg;

Succinylcholine 1 mg/kg iv. or vecuronium 0.1 mg/kg iv.Succinylcholine 1 mg/kg iv. or vecuronium 0.1 mg/kg iv. Sedation/analgesia should be continued, using short-acting drugs so that neurological Sedation/analgesia should be continued, using short-acting drugs so that neurological assessments can be made at regular intervals in the assessments can be made at regular intervals in the ED. ED. Muscle relaxing drugs should be Muscle relaxing drugs should be avoided if possible.avoided if possible.

Recommended sedation protocol for ETI in TBI – Italian guidelines, 1999


Priorities in the treatment of severe head injuries:Priorities in the treatment of severe head injuries:What about sedation?What about sedation?

MIDAZOLAM Deo S The use of midazolam in trauma resuscitation. Eur J Emerg Med. 1994 Sep;1(3):111-4.

…… Midazolam was found to be a safe and viable alternative to muscle relaxants, allowing endotracheal intubation and ventilation

Davis DP Prehosp Emerg Care. 2001 Apr-Jun;5(2):163-8.

…….The use of midazolam with prehospital RSI is associated with a dose-related incidence of hypotension.



ETOMIDATE

1: Dearden NM Comparison of etomidate and althesin in the reduction of increased Dearden NM Comparison of etomidate and althesin in the reduction of increased intracranial pressure after head injury. intracranial pressure after head injury. Br J Anaesth. Br J Anaesth. 19851985 Apr;57(4):361-8. Apr;57(4):361-8.

2: Schockenhoff B Use of etomidate within the scope of neurosurgery Zentralbl Neurochir. 2: Schockenhoff B Use of etomidate within the scope of neurosurgery Zentralbl Neurochir. 19851985;46(2):151-5. German. ;46(2):151-5. German.

3: Hinds CJ. Etomidate and adrenocortical function. Intensive Care Med. 3: Hinds CJ. Etomidate and adrenocortical function. Intensive Care Med. 19841984;10(5):268-9. ;10(5):268-9.

4: Cohn BF Results of a feasibility trial to achieve total immobilization of patients in a 4: Cohn BF Results of a feasibility trial to achieve total immobilization of patients in a neurosurgical intensive care unit with etomidate. Anaesthesia. neurosurgical intensive care unit with etomidate. Anaesthesia. 19831983 Jul;38 Suppl:47-50. Jul;38 Suppl:47-50. 5: Prior JG The use of etomidate in the management of severe head injury. Intensive Care 5: Prior JG The use of etomidate in the management of severe head injury. Intensive Care Med. Med. 19831983;9(6):313-20. ;9(6):313-20.

6: Schulte am Esch J, The influence of etomidate and thiopentone on the intracranial 6: Schulte am Esch J, The influence of etomidate and thiopentone on the intracranial pressure elevated by nitrous oxide. Anaesthesist. pressure elevated by nitrous oxide. Anaesthesist. 1980 1980 Oct;29(10):525-9. German. Oct;29(10):525-9. German.


KETAMINE

Bourgoin A. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003 Mar;31(3):711-7

…… ketamine in combination with midazolam is comparable with a combination of midazolam-sufentanil in maintaining intracranial pressure and cerebral perfusion pressure of severe head injury patients placed under controlled mechanical ventilation.



LIDOCAINE

EV lidocaine prevents the increase in ICP that occur during ETI

Many RSI protocols include L several minutes before laringoscopy

No literature could be found to support the use of L as a single agentprior intubation




• the role of cerebral ischemiathe role of cerebral ischemia• ABCsABCs

• Is preH ETI an absolute priority in the management Is preH ETI an absolute priority in the management of the HI?of the HI?• To hyperventilate or not to hyperventilate?To hyperventilate or not to hyperventilate?• What is the gold target for BP? What is the gold target for BP?

• What about sedation?What about sedation?

• How much to rely on the first CT for further developments and prognosis How much to rely on the first CT for further developments and prognosis ??


CT scan 12 hrs laterCT scan 12 hrs later


Timing of CT scanTiming of CT scan• First CT as soon as possible

• Second CT• before 12 hrs if first within 3 hrs after trauma• within 24 hrs

• Third CT before 72 hrs after the trauma

A CT scan must be obtained in case of any clinical deterioration or increase in ICP


How much to rely on the first CT for further developments How much to rely on the first CT for further developments

and prognosis?and prognosis?

Initial scan vsInitial scan vs Worst scan

DI I - DI II - DI III - DI IV - Mass lesionDI I - DI II - DI III - DI IV - Mass lesion

DI I 89% 4% 2% 0% 4%

DI II 81% 4% 1% 14%

DI III 85% 1% 13%

DI IV 80% 20%

Mass lesion 100%

Servadei et al Neurosurgery, Vol 46, n.1, January 2000

How much to rely on the first CT for further developments and How much to rely on the first CT for further developments and

prognosis ?prognosis ?


Which patients are at high risk for ICP elevation?Which patients are at high risk for ICP elevation?

Clinical case: outcomeClinical case: outcome

• The patient remained in the ICU 9 days.• He had intermittent increases of ICP during the

first 4 days responsive to medical treatment• He was operated at the left leg on day 4• He was extubated on day 8• He was transferred to Neurosurgical ward and

now he came back to his work with only a minor paresis of the left arm


ConclusionsConclusions

• Brain ischemia is the most relevant pattern in STBI especially in the first 24 hrs.

• Head injured patients require aggressive approach in the acute phase for the prevention of secondary insults. Hypoxia and hypotension are the most frequent, important (and preventable) complications

• Referral to hospitals with neurosurgical facilities should be the gold standard where surveillance, diagnosis and prompt surgical intervention could be provided in case of detection of mass lesion


No single “magic bullet” has been developedNo single “magic bullet” has been developed

The cornerstone of management of head-injured patients The cornerstone of management of head-injured patients remains the remains the preventionprevention of initial injury and the of initial injury and the minimization minimization

or reversal of secondary insultsor reversal of secondary insults

The cornerstone of management of head-injured patients The cornerstone of management of head-injured patients remains the remains the preventionprevention of initial injury and the of initial injury and the minimization minimization

or reversal of secondary insultsor reversal of secondary insults

Teasdale GM Teasdale GM Neurosurgery 1998Neurosurgery 1998

ConclusionsConclusions


severe traumatic brain injury francesco della corte, md associate professor university a. avogadro,...

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