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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
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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 • 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
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
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
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
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
General critical care concepts specific to the head injured patient
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
Monro/Kellie Doctrine Brain CSF Blood
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
Intracranial Pressure Monitoring • Types • Bolt (subdural screw) • Epidural sensor • Ventriculostomy • Diagnostic • Therapeutic
Cerebral Perfusion Pressure CCP= MAP - ICP
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
Lowering ICP • Options • Sedation • Draining CSF • Hyperosmolar therapy
Triangle of ICU Sedation Analgesia Anxiolytics/Sedation Paralytics Delirium
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
Sedation • Fentanyl • Rapid onset, short duration of action • Usually given as a drip • Some evidence of worsening of CCP (BP, ICP) with bolus
Hyperosmolar Therapy • Mannitol • Osmotic diuretic • Can cause hypotension • Fairly quick onset • Hypertonic saline • Osmotic diuretic • Does not cause hypotension • May increase CPP
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
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
Decompressivecrainectomy • Neurosurgical decision • Violates the Monro-Kellie Doctrine
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
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
Steroids • Only level I data from the Brain Trauma Foundation Guidelines is don’t use steroids
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
Ventilatory Management • Most head injured patients have normal lungs • They don’t all stay that way
Infection prevention/treatment • VAP prevention • Catheter infection prevention • Urinary catheter infection prevention • Fever work ups • Five W’s • Wind • Water • Wounds • Walking • Wonder Drugs
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
Other conditions • Head injured patients are already complicated • Adding other injuries adds to the complexity • Gatekeeper
Ethics • Family discussions • Difficult to predict level of long term impairment sometimes • There can be fates worse than death • Comfort Care
Case Presentation #1 • Fixed and dilated pupils • + Corneals and gag reflexes • Withdraws upper extremities, flexion posturing lower extremities • Intensive family discussions • Comfort care
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
Conclusions • The Trauma Surgeon/Surgical Intensivist plays a core role in the care of the acute brain injured patient