1 / 46

Role of the Critical Care Surgeon in Traumatic Brain Injury

Role of the Critical Care Surgeon in Traumatic Brain Injury. Jon C. Krook, M.D., F.A.C.S. Department of Surgery HCMC. Case Presentation #1. 55 y.o . female, MCA at highway speeds with no helmet Was cut off by an auto and “laid” the bike down, was thrown from the bike

mort
Download Presentation

Role of the Critical Care Surgeon in Traumatic Brain Injury

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Role of the Critical Care Surgeon in Traumatic Brain Injury Jon C. Krook, M.D., F.A.C.S. Department of Surgery HCMC

  2. Case Presentation #1 • 55 y.o. female, MCA at highway speeds with no helmet • Was cut off by an auto and “laid” the bike down, was thrown from the bike • Was initially awake and talking to the first responders but became confused • 10-15 minutes later L pupil became fixed and dilated • Intubated and transported to HCMC

  3. Admission CT

  4. Post-operative CT

  5. Post-operative CT #2

  6. Case Presentation #2 • 23 y.o. in the Air Force, suffered an accidental GSW to the left side of the head • Initially managed at another hospital and then transferred to HCMC

  7. Outside Hospital CT

  8. Outside Hospital CT PID#1

  9. HCMC Arrival CT

  10. Initial assessment

  11. Initial evaluation of the Brain Injured Patient • ATLS primary and secondary survey • Avoid hypoxia and hypotension • Need to prioritize injury management ATLS Primary Survey A AirwayB BreathingC CirculationD DisabilityE Exposure

  12. Initial evaluation of the Brain Injured Patient • ATLS primary and secondary survey • A - Intubate if GCS < 8 or other indication • B - Rule out injury • C - Evaluation/Treatment of shock • D- Evaluation of mental status • E- Look for other injuries • Secondary survey- comprehensive physical exam

  13. Initial evaluation of the Brain Injured Patient • Imaging • Chest, pelvic, +/- c-spine x-rays • FAST exam • Head CT • + LOC • Altered mental status on evaluation • Surgery • Head or other • Prioritization

  14. General critical care concepts specific to the head injured patient

  15. Critical Care Evaluation • All early management of the head injured patient is aimed toward limiting secondary brain injury • Avoid hypotension or hypoxia • Preserve oxygen delivery to the uninjured brain

  16. Monro/Kellie Doctrine Brain CSF Blood

  17. Herniation • Supertentorial Herniation • 1 Uncal (transtentorial) • 2 Central • 3 Cingulate (subfalcine) • 4 Transcalvarial • Infratentorial • 5 Upward (upward cerebellar) • 6 Tonsilar (downward cerebellar) http://en.wikipedia.org/wiki/Brain_herniation

  18. Intracranial Pressure Monitoring • Types • Bolt (subdural screw) • Epidural sensor • Ventriculostomy • Diagnostic • Therapeutic

  19. Cerebral Perfusion Pressure CCP= MAP - ICP

  20. Preserving MAP • Can be challenging in the face of other injuries • Shock • Hypovolemic/hemorrhagic • Cardiogenic • Neurologic • Vasopressors • Can have downsides • May increase driving pressure, but may decrease overall blood flow to the brain

  21. Lowering ICP • Options • Sedation • Draining CSF • Hyperosmolar therapy

  22. Triangle of ICU Sedation Analgesia Anxiolytics/Sedation Paralytics Delirium

  23. Sedation • Propofol • Rapid onset, short duration of action • Important in awaking trials • Depresses cerebral metabolism • Reduces cerebral oxygen consumption • Possibly reduces ICPs through direct methods

  24. Sedation • Fentanyl • Rapid onset, short duration of action • Usually given as a drip • Some evidence of worsening of CCP (BP, ICP) with bolus

  25. Hyperosmolar Therapy • Mannitol • Osmotic diuretic • Can cause hypotension • Fairly quick onset • Hypertonic saline • Osmotic diuretic • Does not cause hypotension • May increase CPP

  26. Phenobarbital Coma • Not done anymore at HCMC • Supplanted by iatrogenic hypothermia • Requires intensive monitoring • Downsides to Phenobarbital • Pneumonia • Feeding intolerance • Cardiac depression • Hypotension from phenobarbital erases any beneficial effect

  27. Hypothermia • Current practice at HCMC • Better outcomes in most RCTs examining hypothermia • Mixed results regarding mortality • None showing worse mortality • Some showing improved mortality • All RCTs report improved GOS (Glasgow Outcome Scale) in those treated with hypothermia

  28. Decompressivecrainectomy • Neurosurgical decision • Violates the Monro-Kellie Doctrine

  29. Anti-Seizure Prophylaxis • Post Traumatic Seizures (PTS) • Early < 7 days • Late > 7 days • No evidence that routine prophylaxis decreases late seizures • Anti-seizure prophylaxis effective in early seizures

  30. Anti-Seizure Prophylaxis • Indications for treatment • GCS < 10 • Cortical contusion • Depressed skull fracture • Subdural hematoma • Intracerebral hematoma • Penetrating head wound • Seizure within 24 h of injury

  31. Steroids • Only level I data from the Brain Trauma Foundation Guidelines is don’t use steroids

  32. General Critical Care Concepts

  33. Ventilatory Management • Most significant head injuries get intubated at some point for airway protection • Some are on significant sedation to impact their ICP • Most weaning protocols end with the assessment of the patient’s ability to follow commands • Therefore many are on ventilators for some time

  34. Ventilatory Management • Most head injured patients have normal lungs • They don’t all stay that way

  35. Ventilatory Management

  36. Infection prevention/treatment • VAP prevention • Catheter infection prevention • Urinary catheter infection prevention • Fever work ups • Five W’s • Wind • Water • Wounds • Walking • Wonder Drugs

  37. Nutrition

  38. VTE Prophylaxis • VTE= VenoThromboEmbolism • Risk of developing DVT in severe brain injury about 20% • Best treatment is prevention • No good data on timing • DEEP study out of Parkland • IVC Filters

  39. Other conditions • Head injured patients are already complicated • Adding other injuries adds to the complexity • Gatekeeper

  40. Ethics • Family discussions • Difficult to predict level of long term impairment sometimes • There can be fates worse than death • Comfort Care

  41. Case Presentation #1 • Fixed and dilated pupils • + Corneals and gag reflexes • Withdraws upper extremities, flexion posturing lower extremities • Intensive family discussions • Comfort care

  42. Case Presentation #2 • Localized to pain on arrival • Ventriculostomy placed • ICPs high • All efforts employed including cooling • Cooled for about a week • Neurologic exam worsened on warming on HD#17

  43. Case Presentation #2

  44. Case Presentation #2

  45. Conclusions • The Trauma Surgeon/Surgical Intensivist plays a core role in the care of the acute brain injured patient

  46. Questions?

More Related