Blood
Pressure Management
·
While
avoidance of (systemic and intracranial) hypotension in the TBI patient is
paramount in preventing secondary brain injury, care must also be taken to
avoid significant systemic (and subsequent intracranial) hypertension.
·
Target
Blood Pressure Parameters:
o
Primary
BP Goal : Maintain MAP >80.
o
Secondary
BP Goal: If MAP>80, then maintain SBP <140.
References on BP Management
·
American College of Physicians. (2015). Best
practices in the management of traumatic brain injury. American
College of Surgeons. (2015). Best practices in the management of traumatic
brain injury. Retrieved from:
·
Hemphill, J.C., Greenberg, S.M., Anderson, C.S.,
Becker, K., Bendok, B.R., Cushman, M., …Woo, D. (2015). Guidelines for the
management of spontaneous intracerebral hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
·
Rossaint,
R., Bouillon, B., Cerny, V., Coats, T.J., Duranteau, J., Fernandez-Mondejar,
E., …Spahn, D.R. (2016). The European guideline on management of major bleeding
and coagulopathy following trauma: fourth edition. Critical Care, 20, 1-55.
Resuscitation:
1. Secondary
injury usually occurs in the ICU.
2.
Hypotension is worse than Hypoxia. Both together is usually fatal.
3.
Be aggressive with lines, ICP management, meds
and IVF until blood products and source control to maintain CPP.
4.
SAFE TBI Trial:
Mortality nearly doubled when given albumin as primary resuscitation.
5.
Use Normal Saline (avoid large quantities to
prevent high chloride levels). Sodium bicarbonate or sodium acetate are other
options.
Indications for Repeat CT
Head (usually performed around 12 hours after initial unless clinical change):
1.
Deterioration in neuro exam / GCS score
2.
Abnormal admission CT Head AND
a.
Unreliable or unobtainable neuro exam
b.
High ISS (>15, ‘severe and critical’)
3.
Presence of mass effect and
unreliable/obtainable exam
4.
Patients on Vitamin K antagonism (Coumadin),
direct thrombin inhibitor or factor Xa inhibitors
5.
Patients on Plavix or full-dose ASA should be
considered for repeat CT Head, regardless of exam, if they require early
restart of ASA/Plavix
Anticoagulated Patients:
CT Head for all trauma patients with known anticoagulation
meds.
Reverse immediately if possible TBI and suspected
anticoagulation. See:
Anticoagulated Trauma Patient Guideline-(http://uktraumaprotocol.blogspot.com/2014/01/anticoagulated-trauma-patient.html)
and
Oral Anticoagulants in Trauma and Surgery Guideline-
(http://uktraumaprotocol.blogspot.com/2013/07/anticoagulants-in-trauma-and-surgery.html)
If antiplatelet
use, then give 1 unit of platelets unless operative TBI then give 2 units of
platelets.
Anti-Seizure Prophylaxis
Phenytoin has been shown to reduce the incidence of early
Post-Traumatic Seizure (within 7 days) but is not recommended for preventing
late seizures. Treat with Dilantin for 7
days only unless a seizure occurs then refer to neurosurgery/neurology for
longer therapy.
Hyperventilation
·
Prophylactic hyperventilation (PaCO2 < 25) is
not recommended. Avoid during the first
24 hours.
·
Maintain normocarbia (PaCO2 35-45)
·
If ICP > 25, consider PaCO2 30-35. Refer to Tier 2 treatment.
·
Once initiated, PaCO2 should be maintained at
this target, even if ICP improves with other therapies.
DVT Prophylaxis
·
DVT develops in 20-30% TBI pts without any
prophylaxis.
·
SCD’s should be applied immediately.
·
LMWH after 24 hrs has small increased rate post-crani
hemorrhage.
·
Consider VTE prophylaxis within 24-72 hours if
low risk for progression and stable repeat CT head. See guideline: http://uktraumaprotocol.blogspot.com/2014/01/using-chemical-dvt-prophylaxis-in.html
·
Consider IVC Filter if high risk for TBI
progression especially if long bone fx or pelvic fx
Infection Prophylaxis
·
Peri-procedural atbx for intubation are
recommended by the Brain Injury Foundation to reduce the incidence of PNA but
this is not routine practice of SGB or Neuro-Critical Care at UK.
·
Routine ventricular catheter exchange to reduce
infection in patients with EVD’s is not recommended. ICP monitors and EVDs should be placed under
sterile technique with one dose of a peri-procedural antibiotic.
Minimize manipulation and flushing.
Avoid accessing the EVD bag for
CSF cultures. Notify the neurosurgery
team for assistance with the EVD.
·
Recommend vancomycin/cefepime/metronidazole for
7 days for open skull fx.
Tracheostomy
·
If level of consciousness stays low, trach may
facilitate vent separation and decrease risk of PNA
·
Relative contraindications: High ICP, unstable, Severe ARF
·
Guidelines suggest consider ‘early’ trach by HD
8; though most patients can be identified as eligible and appropriately undergo
trach much sooner.
Nutrition
·
Initiate enteral nutrition as soon as possible.
·
Attain full caloric replacement by day 7 post-injury.
·
See Nutrition Support Guideline: http://uktraumaprotocol.blogspot.com/2013/04/nutrition-support-guideline.html
Steroids
Not recommended.
Increases mortality in moderate to severe TBI.
Prognosis / Withdrawal of
Care:
·
In general, severe TBI pts should receive full
treatment for at least 72 hours post-injury.
·
Withdrawal of Life-Saving Treatment within 72
hours should be weighed against the patient’s exam especially if brainstem
findings and against the patient’s previously stated wishes.
·
Age alone should not be a valid reason for
tx-limiting decisions.
·
Caution when using prognostic models for
individuals.
·
Patients with TBI should undergo standardized
outcome assessment using the GOS-E at 6 months.
Propranolol:
· In patients with severe TBI (head AIS >=3), propranolol has been shown to reduce mortality and improve functional outcome (Glasgow Outcome Scale-Extended, GOSE)
· Dosing: 20mg q12h until discharge or for at least 10 days
· Start when hemodynamics permit
