Traumatic Brain Injury · DVT Level I Level IIA Level III Insufficient data Insufficient LMWH or low dose fractionated heparin may be used in combination with mechanical prophylaxis

$Page 1: Traumatic Brain Injury · DVT Level I Level IIA Level III Insufficient data Insufficient LMWH or low dose fractionated heparin may be used in combination with mechanical prophylaxis$
Traumatic Brain Injury:Changes in Management Across the Spectrum of

Age and Time

Omaha 2018 Trauma SymposiumJune 15, 2018

Gail T. Tominaga, M.D., F.A.C.S.Scripps Memorial Hospital La Jolla

Outline

Background

Basic principles of TBI management

Brain Trauma Foundation 2016

Pediatric Traumatic Brain Injury Guidelines 2012

Traumatic Brain Injury

Leading cause of death in Americans < 45 years of age

Leading cause of death & acquired disability in childhood

75% have other significant injuries

https://www.cdc.gov

https://www.cdc.gov/traumaticbraininjury/data/rates_hosp_byage.html

https://www.cdc.gov/traumaticbraininjury/data/dist_death.html

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 < 25 mm Hg 29

Corticosteroids use more than half the time 64

Crit Care Med 23: 560‐567, 1995

Findings

ICP monitoring used infrequently

Severe hyperventilation

Use of steroids currently not indicated

Wide variability in practice

Brain Injury

PRIMARY Immediate damage

SECONDARY Indirect injury

Delayed

Due to:

Inadequate blood flow

Inadequate substrate deliveryCan lead to cell death and

worsening damage to the brain

Controlling Secondary Brain Injury

Operable LesionsSubdural hematoma Depressed skull fractures


Hypotension


Hypotension

SBP < 90 mmHg

TCDB, 717 pts: mortality 27% to 50%*

Mortality increased: 34 to 75%**

Bad outcome (dead, disabled, pvs) increased: 24 to 88%***

*Chestnut. JOT. 34(2), 1997.

**Gentleman. Lancet. 2:853, 1981.***Kohi et al. Injury. 16:25, 1984.


Hypotension

AVOID Hypotension

Adequate fluid resuscitation

EUVOLEMIA

Preferred: Normal saline (308 mOsm)

Others: LR (273 mOsm)

Consider: 3% saline


Hypoxia

Hypoxemia pO2 < 60mmHg: 23‐46%

Increases mortality from 34 to 59%

Poor outcome increases from 28 to 71%


Elevated ICP

•Creates pressure gradients within the skull (herniation)

•Compromises cerebral perfusion pressure ischemia (esp end vessels)

Brain -- CSF -- Blood


Cerebral Perfusion Pressure

CPP = MAP ‐ ICP

•Normal 70‐100 mmHg

•Adequate 50‐60 mm Hg

• Ischemic 30‐40 mmHg

Treatment of Elevated ICP

Elevate HOB

Oxygenation

Hyperventilation (mild)

Sedation

Neuromuscular blockade

Osmotic diuretics

Seizure control

Mild hypothermia

CSF drainage

Barbiturate coma

Decompressive Craniectomy

Brain Trauma Foundation Guidelines for Severe TBI

Date Title Comment

2007 Guidelines for Prehospital Management of TBI, 2nd ed Rec in 7 topic areas; based mostly on Class III evidence

2006 Guidelines for Surgical Management of Severe TBI

2007 Guidelines for Management of Severe TBI, 3rd edition* Rec for 15 clinical areas, ranking from Level I to III.

2006 Guidelines for the Prehospital Management of TBI, 2nd edition Pediatric sections added

2000 Early Indicators of Prognosis in Severe TBI

1999 Guidelines for Management of Severe TBI, 2nd edition

1995 Guidelines for Management of Severe TBI, 1st edition

* Endorsed by principal neurosurgery organizations


CSF drainage

Osmotic diuresisMild Hypothermia

Neuromuscular blockadeMild hyperventilation

Elevate HOB; SedationSeizure control and prophylaxis

Avoid hyperthermia

AVOID HYPOTENSION (Adequate fluid resuscitation)AVOID HYPOXIA (Early airway, oxygen)

Barbiturate Coma


Brain Trauma Foundation Guidelines for Severe TBI

Date Title Comment

2016 Guidelines for the Management of Severe TBI, 4th ed* Rec in 28 topics; based on 5 Class I studies, 46 Class 2, 136 Class III, 2 meta-analyses

2012 Guidelines for Severe TBI in Infants, Children, & Adolescents, 2nd ed* Rec for 8 topic areas; based on Class II and III evidence

* Endorsed by principal neurosurgery organizations

Guidelines for Management of Severe TBI

Systematic evidence review and synthesis

Screened for scientific and statistical validity

Classified:

Class Qualification

1 Good quality randomized trials

2 Moderate quality randomized trials, good quality cohort or case-control studies

3 Low quality randomized controlled trials, mod-low quality cohort or case-control studies, case series

Guidelines for Severe TBI in Infants, Children, & Adolescents, 2nd ed

Systematic evidence review and synthesis

Screened for scientific and statistical validity

Classified:

Class Qualification

1 Good quality randomized trials

2 Moderate quality randomized trials, good quality cohort or case-control studies

3 Low quality randomized controlled trials, mod-low quality cohort or case-control studies, case series

Guidelines for Management of Severe TBI, 4th ed

Level of Recommendations

Level Qualification

I High quality body of evidence

IIA Moderate quality body of evidence

IIB Body of evidence with Class 2 studies that provided direct evidence but were of overall poor quality

III Body of evidence with Class 3 studies or Class 2 studies providing only indirect evidence


Studies: 5 Class 1, 46 Class 2, 136 Class 3, 2 meta‐analysis

TREATMENTS MONITORING THRESHOLDS

Decompressive Craniectomy ICP BP

Prophylactic Hypothermia CPP ICP

Hyperosmolar tx Advanced cerebral monitoring CPP

CSF drainage Advanced cerebral monitoring

Ventilator therapies

Anesthestics, Analgesia, Sedation

Steroids

Nutrition

Infection Prophylaxis

DVT Prophylaxis

Seizure Prophylaxis


DECOMPRESSIVE CRANIOTOMY

Level I Level IIA PEDIATRIC GUIDELINESInsufficient data Bifrontal DC is not recommended to

improve outcomes ( GOS-E at 6 months post-injury)

Reduces ICP and minimizes ICU LOS Large F-T-P DC ( > 12 x 15 cm)

recommended

DC with duraplasty, leaving the bone flap out, may be considered for pediatric patients with TBI who are showing early signs ofneurologic deterioration or herniation or are developingintracranial HTN refractory tomedical management during the early stages of their treatment



Are there Prospective Randomized Studies?

DECRA: Decompressive Craniectomy in Diffuse Traumatic Brain Injury

RESCUEicp: Randomized Evaluation of Surgery with Craniectomy for Uncontrolled Elevated Intracranial Pressure

• Dec 2002 – April 2010• N = 155; age 15‐59 yrs; GCS 3‐8; 72 hrs• Severe diffuse TBI and intracranial HTN refractory to first‐tier therapies

• Bifrontotemporoparietal DC vs Standard Care

Intracranial Pressure before and after Randomization

Cooper DJ et al. N Engl J Med 2011;364:1493‐1502

Cumulative Proportions of Results on the Extended Glasgow Outcome Scale

Cooper DJ et al. N Engl J Med 2011;364:1493-1502

DECRA

“In adults with severe diffuse TBI and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and length of stay in the ICU but was associated with more unfavorable outcomes.”

• 2004‐2014; 40 centers in 17 countries

• 408 patients; ge 10‐65 years

• Severe diffuse TBI and intracranial HTN (> 25 mm Hg) refractory to first and second tier therapies

• DC vs Medical Treatment

DC in Pediatric TBI

Taylor ‐ Pediatric Single center RCT N = 27, 1991‐1998

Age 1.8‐15 years

ICP > 20 mm Hg in first 24 hrs or evidence of herniation

F/U 6 months

57% favorable outcome in DC vs 14% in medical group


Decreases ICP

Increases CPP

Improves PbtO2

More unfavorable outcomes


PROPHYLACTIC HYPOTHERMIA

Level I Level IIA Level IIB PEDIATRIC GUIDELINESInsufficient data

Insufficient data

Early (within 2.5 hrs), short term (48 hrs), prophylactic hypothermia is NOT recommended

(II) Avoid mod hypothermia (32-33oC) beginning early after severe TBI for only 24 hours

(II) Consider mod hypothermia beginning within 8 hrs after severe TBI for up to 48 hrs duration to reduce ICP

(II) If hypothermia is induced, rewarming at a rate of > 0.5oC per hour should be avoided


HYPEROSMOLAR THERAPY

4th edition

3rd edition

Level I Level IIA Level IIB PEDAITRIC GUIDELINESInsufficient data

Insufficient data (II) Hypertonic saline should be considered for tx of severe TBI with elevated ICP (6.5-10 ml/kg)

(III) HTS should be considered for tx of severe pediatric TBI with elevated ICP 9dose 3% saline continuous dose 0.1-1.0 ml/kg/hr to maintain ICP < 20 mmHg & serum osm < 300 mOsm/L

Level I Level II Level IIIInsufficient data Mannitol effective for control of elevated

ICP (0.25 mg/kg – 1 g/kg); avoid SBP < 90 mm Hg

Restrict use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurologic deterioration


CSF DRAINAGE

Level I Level IIA Level III PEDIATRIC GUIDELINESInsufficient data Insufficient data EVD system zeroed at midbrain with

continuous drainage may be considered to lower ICP

Use of CSF drainage to lower ICP in pts with initial GCS < 6 during the 1st

12 hrs after injury may be considered

(III) CSF drainage via an EVD may be considered in the management of increased ICP in children with severe TBI.

(III) Addition of a lumbar drain may be considered in the case of refractory intracranial HTN with a functioning EVD, open basal cisterns, and no evidence of a mass lesion orshift on imaging studies.


VENTILATION THERAPIES

4th edition

3rd edition


Insufficient data

Prolonged prophylactic hyperventilation with PaCO2 < 25 is NOT recommended

(III) Avoid prophylactic severe hyperventilation (paCO2 < 30 mm Hg may be considered in initial 48 hrs after surgery(III) If hyperventilation is used to manage refractory intracranial HTN, advanced neuro monitoring for cerebral ischemia may be considered

Level I Level II Level 3Insufficient data Prophylactic hyperventilation

NOT recommended Hyperventilation recommended as a temporizing

measure to reduce elevated ICP Hyperventilation should be avoided during the

1st 24 hrs after injury


ANESTHETICS, ANALGESICS, SEDATIVES


Insufficient data

Barbiturates to induce burst suppression (EEG) is NOT recommended as prophylaxis against development of intracranial HTN

High-dose barbiturates is recommended to control elevated ICP refractory to maximum standard medical and surgical tx.

Propofol is recommended for the control of ICP but is not recommended for improvement in mortality or 6 month outcome. Caution required as high-dose propofol can produce significant morbidity

(III) Etomidate may be considered to control severe intracranial HTN

(III) Thiopental may be considered to control intracranial HTN


STEROIDS

Level I Level IIA PEDIATRIC GUIDELINESUse of steroids NOT recommended

(II) Use of steroids not recommended


NUTRITION

Level I Level IIA Level IIB PEDIATRIC GUIDELINESInsufficient data Attain basal caloric replacement

at least by 5th day and at most 7th days post injury (to decrease mortality)

Transgastric jejunal feeding is recommended to reduce the incidence of VAP

(II) Evidence does not support the use of immune-modulating diet for the tx of severe TBI to improve outcome


DVT

Level I Level IIA Level IIIInsufficient data Insufficient LMWH or low dose fractionated heparin may be

used in combination with mechanical prophylaxis (increased risk for expansion of ICH)

Insufficient evidence of support recommendation of preferred agent, dosing, or timing of pharmacologic agent.


SEIZURE PROPHYLAXIS

Level I Level IIA Level III PEDIATRIC GUIDELINESInsufficient data

Prophylactic use of phenytoin or valproate is NOT recommended for late PTS

Phenytoin is recommended to decrease the incidence of early PTS (within 7 days)

Insufficient evidence to recommend levetiracetam compared with phenytoin regarding efficacy in preventing early PTS and toxicity

(III) Prophylactic tx with phenytoin may be considered to reduce the incidence of early PTS


INFECTION

Level I Level IIA Level IIIInsufficient data Early tracheostomy is recommended to

reduce mechanical ventilator days when the overall benefit is thought to outweigh the complications. There is no evidence that early tracheostomy reduces mortality rate or rate of nosocomial infection.

• The use of providone-iodine is NOT recommended to reduce VAP and may cause an increase risk of ARDS.

Antimicrobial impregnated catheters may be considered to prevent catheter-related infection during external ventricular drainage


BLOOD PRESSURE THRESHOLDS

Level I Level IIA Level IIB Level IIIInsufficient data Insufficient data Insufficient data Age 15-29 yrs: maintain SBP > 110 mm Hg

Age 50-69 yrs: maintain SBP > 100 mmHg Age > 70 yrs: maintain SBP > 110 mmHg


ICP MONITORING & THRESHOLDS

Type of Monitoring

Level I Level IIA Level IIB Level III PEDIATRIC GUIDELINES

ICP Insufficient data

Insufficient data

Management of severe TBI using information from ICP monitoring is RECOMMENDED to reduce in-hospital and 2-week post-injury mortality

NO LONGER SUPPORTED Use in pts with GCS 3-6 after

resuscitation and abnormal CT Use in pts with severe TBI with

normal CT scan with > 2 of the following: age > 40 yrs, motor posturing, or SBP < 90 mmHg

(III) Consider use in pediatric pt with severe TBI

ICP threshold

Insufficient data

Insufficient data

Treat ICP > 22 mm Hg (increased mortality associated with ICP > 22)

Combination of ICP, clinical an brain CT findings may be used to make management decisions

(III) Treatment ICPthreshold of 20 mm Hg.


CPP MONITORING & THRESHOLDS

Type of Monitoring


CPP Insufficient data

Insufficient data

Management of severe TBI patients using guidelines-based recommendations for CPP monitoring is recommended to decrease 2-wk mortality

CPP threshold

Insufficient data

Insufficient data

Recommended target CPP for survival and favorable outcomes is 60-70 mmHg(depends on autoregulatory status of the patient)

Avoid aggressive attempts to maintain CPP > 70 mm Hg with fluids and pressors (risk of ARDS)

(Level III): Minimum CPP 40 mmHg


ADVANCED CEREBRAL MONITORING & THRESHOLDS

Type of Monitoring


Advanced cerebral monitoring

Insufficient data

Insufficient data

Insufficient data

Jugular bulb monitoring of AVDO2as a source of information for management decisions may be considered to reduce mortality and improve outcomes at 3 and 6 months post injury

Advanced cerebral monitoring threshold

Insufficient data

Insufficient data

Insufficient data

Jugular venous saturation of < 50% may be a threshold to avoid

(III) If brain oxygenation monitoring is used, maintenance of partial pressure of brain tissue oxygen (PbtO2) 10 mm Hgmay be considered.

Revised Treatment Scheme


+Barbiturates

Mild Hyperventilation*

ICP Monitoring –

Hyperosmolar therapy

ICP Monitoring – CSF Drainage

Elevate HOB; SedationSeizure control/prophylaxis; Nutrition;

Avoid hyperthermia

AVOID HYPOTENSION (Adequate fluid resuscitation)

AVOID HYPOXIA (Early airway, Oxygen)

*PaCO2 35; Titrate to avoid SjvO2 < 60 or PbtO2 <15

If refractory intracranial hypertension despite medical intervention Head CT without contrast STAT (If no head CT since ICP elevation

Significant Mortality and Morbidity Reductions

Rapid transport to a trauma care facility

Prompt resuscitation

CT scanning

Prompt evacuation of significant intracranial hematomas

ICP monitoring and treatment

Summary

Avoid Secondary Brain Injury

EARLY evacuation of mass lesions

AVOID HYPOTENSION

AVOID HYPOXIA

Initial Assessment / Management

ABCD; Early intubation

Avoid excessive hyperventilation

Fluid resuscitation

Look for other injuries

Summary

Coagulopathy

Correct to decrease chance of lesion evolution

Metabolic issues

Avoid dextose & hypotonic fluids

Avoid hyponatremia

Fevers are bad for ICP

Early nutrition

Summary

ICP & CPP

Elevate HOB

Maintain SBP > 100‐110 mm Hg

Maintain ICP < 22; CPP > 60

Do not hyperventilate

Short acting sedatives

Mannitol intermittent bolus dosing


Documents

Traumatic Brain Injury · DVT Level I Level IIA Level III Insufficient data Insufficient LMWH or low dose fractionated heparin may be used in combination with mechanical prophylaxis