DR. P.K WANYOIKECONSULTANT NEUROSURGEON

1ST TRAUMA SYMPOSIUMKENYATTA NATIONAL HOSPITAL

19-04 2013

ACUTE NEUROTRAUMAACUTE TRAUMATIC BRAIN INJURY

ACUTE SPINAL CORD INURY

NEUROTRAUMA(stadards for surveilance of

neurotrauma, who, cdc 1995)

TRAUMATIC BRAIN INJURY-Defined as injury to the head {blunt or penetrating trauma by either accelerating or decelerating forces } and with either

1)observed or self reported loss of consciousness.

2)Neurologic or psychological changes, skull fracture or intracranial lesions

3)Death as a result of trauma in patient with head injury

PENETRATING

MISSILE TBI

EXCLUDESLacerations, avulsions or contusions of the

face, ear, eyes, scalp without the criteria above

Fractures of facial bonesBirth trauma Inflammatory, Infections metabolic, or

encephalopathies not related to brain traumaCerebral anoxia and brain infarction not

trauma relatedBrain tumors

SPINAL TRAUMAAcute traumatic lesion of neural elements in

the spinal canal(spinal cord or cauda equina) resulting in temporary or permanent sensory deficit, motor deficit, or autonomic dysfunction. It maybe complete or incomplete.

EXCLUDES SPINE FRACTURES WITHOUT NEUROLOGICAL DEFICIT

COMPLETE TRANSECTION

DECOMPRESSIONSTABILIZATIONNEUROLOGY UNCHANGEDEARLY REHAB.

BURST COMPRESSION CAUDA EQUINAMOTOR GRADE 2

LORDOSIS MAITAINEDFULL POWER REGAINEDSPHICTERS REGAINEDGOOD PRE-HOSP. CAREFROM DJIBOUTI TO NRBAND BACK

HAPPY PATIENT AND DOCTOR

INTRODUCTIONTRAUMATIC BRAIN INJURY (TBI) IS A

MAJOR CAUSE OF DISABILITY, DEATH AND ECONOMIC COST TO OUR SOCIETY.

NEUROLOGICAL DAMAGE EVOLVES OVER ENSUING HOURS AND DAYS DUE TO SECONDARY AND DELAYED INSULTS

KNH 2012 STATISTICSACUTE TRAUMA----5358HEAD INJURIES------1513(28%)SPINE-------------------150PERCENTAGE NEUROTRAUMA---31%

ENTRY POINT

WELL EQUIPED EMMERGNCY ROOM

KNH ACUTE ROOM

MORTALITYUSE OF EVIDENCE BASED PROTOCALS

HAS REDUCED MORTALITY FROM 50% TO 35% TO 25% OVER THE LAST 30 YEARS (j. of neurotrauma 2007)

AUDIT OF ICU ADMISSIONS BETWEEN JAN AND MARCH 2013 AT KNH SHOWED A MORTALITY RATE OF 30% TO 40%

AUDIT OF 105 CASES BETWEEN JUNE AND DEC 2012-SHOWED A MORTALITY OF 19%.

FIVE MOST POWERFUL PREDICTORS OF OUTCOME IN SEVERE TBI PTS.HYPOTENSION(SBP LESS THAN 90mHg)AGEADMISSION GCSINTRCRANIAL DIAGNOSISPUPILLRY STATUS

HYPOTENSION AND OXYGENATIONAVOID SBP <90mmHg(Avoid hypoxia(PaO2 <60mmHg or O2

saturation<90%)Median hypoxemia of 11.5 to 20mins-a

powerful predictor of mortality(p=0.024)Chestnut rm,Marshall lf.,Klauber mr,et.al the role of

secondary brain injury in determining outcome from severe head injury.j trauma 1993:34:216-222

AGEAGE IS AN IDEPEDENT PREDICTOR OF

MORTALITY AND EARLY OUTCOME

ADULTS > 75YRS. HAVE HIGHEST MORTALITY FOLLOWED BY INFANTS 0-4YRS. AND ADOLESCENTS 15-19 YRS.

GCSMOTOR-1unresponsive,2 extends, 3abnormal

flexure, 4 withdraws, 5 localises, 6 spontaneous

VERBAL-1 no response, 2 incomprehensible,3 inapropriate, 4confused, 5 oriented

EYE OPENING-1 none, 2to pain, 3command, 4 spontaneous

GLASGOW OUTCOME SCORE1 DEATH2PERSISTENT VEGETATIVE STATE3SEVERE DISABILITY4 MODERATE5 MILD DISABILITYAPPLIES TO PATIENTS WITH BRAIN

DAMAGE ALOWING OBJECTIVE ASSESMENT OF THEIR RECOVRY,REHABILITATION AND RETURN TO WORK

PREDICTIVE INDICATORSGCS < 7CT SCAN – LARGE CLOT AND MASSIVE

BIHEMISPHERIC CLOTAGE – OLD AGEPUPILLARY LIGHT REFLEX –DILATED PUPILDOLLS EYE SIGHN- ABSENTCALORIC TEST- EYES DO NOT DEVIATEMOTOR RESPONSE – DECEREBRATIONPOSTTRAUMATIC AMNESIA > 2 WEEKS

MANAGEMENT FACTORS INFLUENCING OUTCOME IN SEVERE TBI PTS.Blood pressure and oxygenationHyper-Osmolar therapyProphylactic hypothermiaInfection prophylaxisDVT prophylaxisICP monitoringCerebral perfusionAnesthesia, analgesics and sedativesNutritionAEDs (anti-seizure prophylaxis)HyperventilationSteroids

Hyperosmlar therapyMannitol 0.25mg to 1g/kg body weight.Single loading dose or as a prolonged

therapy for raised icpLower bp and cppHypertonic saline-lowers icp while

maintaining hemodynamics( esp. important In pediatrics)

Spcial precaution of central myelinosi in pts. With hyponatremia

Hypothermia Evidence from 6 RCTs have not shown any

statiscally sinificant reduction in mortality but there was favourable neulological outcomes.

Alderson p.et. Altherapeutic hypothermia for head injury.cochrane database syst. Rev. 2004:4:CDOO1048.

Infection prophylaxisPeriprocedural antibiotics for intubation to

reduce incidence of pneumonia RECOMEDED Routine Ventricular catheter antibiotic

prophylaxis is not recomededventyriculostomies and icp monitors should

be placed under sterile conditionsprolonged antibiotics use in intubated tbi pts

leads to ressistance.

DVT PROPHYLAXISGraduated compression stockings or intermittent

pneumatic compressiuon (IPC)stockings

Low molecular weight heparin or low dose unfractionated heparin(risk of expansion of intracranial hemorrhage)

No medication of choice or optimal dosing according to current evidence

Nurmohammed mt. et, al.low molecular weihgt heparin andcompression stockingsin the prevention of dvt in neurosurgery. Thromb hemostat1996:75:233-238

ICP MONITORINGShould be done in all salvageable patients

with severe traumatic brain injury(GCS of 3-8 after resuscitation) and an abnormal ct scan.

IN patients with a TBI and normal ct scan, ICP monitoring is indicated if two of the following are noted.age >40yrs.unilateral or bilateral motor posturing or SBP<90mmHg.

Cremor o et al. effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury.crit. Care med2005:33:2207-2213

ICP MONITORING TECHNOLOGYVENTRICULAR CATHETER CONNECTED TO AN

EXTERNAL STRAIN GAUGE-the most accurate, low cost and reliable method of monitoring icp.and can be re-calibrated in situ

PARENCHYMAL ICP MONITORS CANNOT BE RE-CALIBRATED

Treatment initiated with ICP THRESHOLD ABOVE 20 mm Hg

Need for treatment based on a combination of icp values, clinical and brain CT scan findings

Saul TG, Ducker TB. Effects of intracranial of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J neurosurg1982 56: 498-503

Cerebral perfusionAggressive attempts to maintain CPP above 70

mmHg with fluids and pressors should be avoided because of the risk of adult respiratory distress syndrome – ARDS

CPP< 50 mmHg should be voided as its associated with poor outcome due to low cerebral perfusion and hence cerebral hypoxia.

RANGE 50-70 mmHgBouma CJ et al blood pressure and intracranial pressure-

volume dynamics in severe head injury:relationship with cerebral blood flow.j neurosurg 1992 77: 15-19

BRAIN OXYGEN THRESHOLDJUGULAR VENOUS OXYGEN SATs 50- 55

ASSOCIATED WITH POOR OUTCOME (SjO2<50-55).

Anesthetics, analgesics and sedativesHigh dose barbiturates administration is

recommended to control ICP refractory to maximum standard medical and surgical treatment.

Propofol is recommended for control of ICP but High doses can produce significant morbidity

Cruz j adverse effects of pentobarbital on cerebral venous oxygenation of comatose patients with acute traumatic brain

swelling. relationship to outcome.j neurosurg1996:85 758 761.

NUTRITIONAIM IS TO ACHIEVE FULL CAROLIC

REPLACEMENT BY 7DAYS. START FEEDING NO LATER THAN 72 HOURS

AFTER INJURYEITHER GASTRIC, JEJUNAL OR PARENTERALDATA SHOW THAT STARVED TBI PATIENTS

LOSE SUFFICIENT NITROGEN TO LOSE WEIGHT BY 15% PER WEEK

HUCKLEBREBERY ET AL .NUTRITIONAL SUPPORT AND THE SURGICAL PATIENT.AM J HEALTH SYST PHARM 2004:61:671-4

ANTI EPILEPTIC DRUGSINDICATED IN ACUTE TBI WITH EARLY

ONSET SEIZUERSCANNOT PREVENT LATE ONSET SEIZURES

HENCE NO ROLE FOR PROPHYLAXISPROPHYLAXIS IN COMATOSE AND

INTUBATED PATIENTS

USE OF STEROIDSCONTRAINDICATED IN ACUTE TBI

CURRENT EVIDENCE SHOW AN 18% RISK OF DEATH IN PATIENTS ADMINISTERD STEROIDS TO THOSE NOT ON STEROIDS

Alderson et al.Corticosteroids for acute traumatic brain injury. The database for of systemic reviews 2005, issue 1

BEST OUTCOMEEFFICIENT PRE-HOSPITAL CAREGOOD HOSPITAL CAREACUTE RESUSCITATIONHEMODYNAMIC NORMALIZATIONEARLY BRAIN CT SCANSURGICAL AND /OR MEDICAL

INTERVENTIONADEQUATE CRITICAL CAREREHABILITATION

GOOD DEDICATED THEATER

AMERICAN STATISTICS(cdc)1.4 million americans sustain TBI annually50,000 people die475,000 children and adolescents 0-14 years80000-90,000 long term disabilityMales twice as likely to sustain tbi than

femalesFalls, mvas,trauma, assault( mvas ,

assault,falls, trauma--knh)

AVOID THIS

LOOKS LIKE BRAIN

DON’T TOUCH

WHAT IS THE KENYAN SITUATIONFOOD FOR NEXT SYMPOSIUM

KNH NEUROSURGERY