Traumatic Brain Injury

 

 

 

Considerations

 

  • Trauma/ATLS approach

  • Possible C-spine injury

  • Monitoring & managing ↑ ICP:

    • Risk of cerebral ischemia & brain herniation

  • Prevention of secondary brain injury:

    • Avoid hypoxia, hypercarbia

    • Maintain adequate CPP (60-70)

    • Avoid hyperglycemia, hyperthermia

  • Multisystem complications:

    • CNS: herniation, seizures

    • CVS: myocardial dysfunction and ST changes, arrhythmias

    • Pulmonary: neurogenic pulmonary edema

    • DIC (disseminated intravascular coagulopathy) 

    • DI (diabetes insipidus), SIADH (syndrome of inappropriate ADH), CSW (cerebral salt wasting)

 

 

Neurosurgical Considerations

 

  • Limited airway access

  • Optimization of surgical exposure

  • Invasive monitoring

  • Complications:

    • Venous air embolism

    • Hemorrhage

    • Arrhythmias and hemodynamic instability

 

 

Goals

 

  • Assess severity of TBI

  • Prevent secondary brain injury:

    • Hypoxia (PaO2 > 60 mmHg)

    • Hypercarbia (PaCO2 35mmHg)

    • Hypotension, maintain CPP ~ 60 mmHg (MAP ~ 80)

  • Avoid abrupt ↑ in BP & ICP (< 20-25mmHg)

  • Avoid hyperthermia & hyperglycemia

  • C-spine precautions

  • Hct > 30

 

 

Conflicts

 

  • Full stomach vs. ↑ ICP

  • Hemorrhage/hypovolemia vs. ↑ ICP

  • Difficult airway vs. ↑ ICP 

 

 

Treatment of ↑ ICP

 

  • Elevate HOB

  • Loosen collars, ETT ties to promote venous drainage

  • Decrease intrathoracic pressures (change ventilator settings, decrease PEEP)

  • Hyperventilation to PaCO2 30 for a brief period only of ~30 min  

  • Sedate

  • Analgesia

  • Paralysis

  • Barbiturate coma (1-5 mg/kg sodium thiopental then 1-3 mg/kg/hr)

  • Hypothermia (or at least normothermia)

  • Mannitol (0.5-1 g/kg)

  • Furosemide (0.25-0.5 mg/kg)

  • Hypertonic saline 6-8 ml/kg of 3% saline

  • Correct sodium and osmolality

  • CSF drainage

  • Surgical decompression (head, abdomen)  

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