Traumatic Brain Injury
Considerations
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Trauma/ATLS approach
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Possible C-spine injury
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Monitoring & managing ↑ ICP:
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Risk of cerebral ischemia & brain herniation
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Prevention of secondary brain injury:
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Avoid hypoxia, hypercarbia
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Maintain adequate CPP (60-70)
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Avoid hyperglycemia, hyperthermia
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Multisystem complications:
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CNS: herniation, seizures
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CVS: myocardial dysfunction and ST changes, arrhythmias
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Pulmonary: neurogenic pulmonary edema
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DIC (disseminated intravascular coagulopathy)
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DI (diabetes insipidus), SIADH (syndrome of inappropriate ADH), CSW (cerebral salt wasting)
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Neurosurgical Considerations
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Limited airway access
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Optimization of surgical exposure
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Invasive monitoring
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Complications:
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Venous air embolism
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Hemorrhage
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Arrhythmias and hemodynamic instability
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Goals
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Assess severity of TBI
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Prevent secondary brain injury:
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Hypoxia (PaO2 > 60 mmHg)
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Hypercarbia (PaCO2 35mmHg)
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Hypotension, maintain CPP ~ 60 mmHg (MAP ~ 80)
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Avoid abrupt ↑ in BP & ICP (< 20-25mmHg)
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Avoid hyperthermia & hyperglycemia
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C-spine precautions
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Hct > 30
Conflicts
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Full stomach vs. ↑ ICP
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Hemorrhage/hypovolemia vs. ↑ ICP
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Difficult airway vs. ↑ ICP
Treatment of ↑ ICP
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Elevate HOB
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Loosen collars, ETT ties to promote venous drainage
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Decrease intrathoracic pressures (change ventilator settings, decrease PEEP)
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Hyperventilation to PaCO2 30 for a brief period only of ~30 min
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Sedate
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Analgesia
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Paralysis
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Barbiturate coma (1-5 mg/kg sodium thiopental then 1-3 mg/kg/hr)
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Hypothermia (or at least normothermia)
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Mannitol (0.5-1 g/kg)
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Furosemide (0.25-0.5 mg/kg)
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Hypertonic saline 6-8 ml/kg of 3% saline
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Correct sodium and osmolality
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CSF drainage
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Surgical decompression (head, abdomen)