Neuro-critical Transfers NE NC London Critical Care Network

Case summary 65 year old brought to ED after a fall while coming out of pub. Confused and agitated. Contusion over right temporal region Smelling of alcohol SpO2 96%; HR 95/m; BP 140/90

What is your immediate concern? How will you manage this case? What will you do? What is your immediate concern? How will you manage this case? ATLS Protocol; ABCDE approach Cervical stabilisation? Agitated patient Prevention of secondary brain injury is priority

Anatomy & relevance of secondary brain injury Prevention of secondary brain injury Why this is important? Cerebral perfusion pressure Why it is important to maintain it? Discuss Rigid skull, Mass effect of expanding brain- Monro-Kellie Doctrine Autoregulation, CBF and ICP and effect on Cerebral perfusion Pressure

Severity of brain injury GCS Score- what are the components? E V M Severity of brain injury based on GCS Mild ? GCS Moderate Severe Explain GCS and how it is calculated. Mild GCS13-15 Moderate GCS 9-12 Severe GCS 3-8

Indication for CT Scan CT Scan High Risk Patient GCS score still < 15 two hours after injury Neurologic deficit Open skull fracture Sign of basal skull fracture Extremes of age

Indication for CT Scan CT Scan Moderate risk patients “Dangerous mechanism” Retrograde amnesia > 30 minutes in duration Severe headache Vomiting > 2 episodes GCS < 13 Warfarin or bleeding disorder Different rule for non-trauma and Age < 16 year

Difference between extradural and subdural Diffuse injury Vs localised Subdural Vs Extradural Midline shift?

Management priorities ABCDE Prevention of Secondary brain injury Adequate oxygenation Adequate ventilation Adequate blood pressure Focussed neurological exam GCS Pupil Lateralising signs Elaborate more on individual part if time permits

After Initial management Transfer of image & Referral to neurosurgical centre Time critical Transfer

Airway Indications for intubation Secured with ET tube RSI induction Low GCS <9 Rapidly falling GCS >2 points Control of PaO2 & PaCO2 Significant oral / Max Fax bleeding Secured with ET tube RSI induction NG insertion

Urgent Neurosurgery ASDH EDH Posterior fossa bleed Acute hydrocephalus SAH with deteriorating GCS

Referral to Specialist Neurosurgical Centre…. Time critical transfer What needs to be done before transfer takes place? Primary vs secondary brain injury

Breathing Mechanical ventilation PaO >11kPa PaCO2 4.5-5.0 Arterial blood gas EtCO2

Circulation 2 x large bore cannula IABP Fluid resuscitation Central line access (but not to cause delay) Ensure good jugular venous drainage MAP >80mmHg (CPP >60mmHg) CPP = MAP - ICP

Disability Reduce Cerebral Metabolic O2 requirements Sedation / Paralysis Treat seizures (Phenytoin 15mg/kg) Pupils Hyperosmolar therapy (1-1.4g/Kg 20% Mannitol) Na <155 Posm <320 BM 6-10

Exposure Normothermia Catheterise …..AND EVERYTHING ELSE!

A Systematic Approach Assessment of the patient Organisational Airway & Cervical spine Breathing -PaO2, EtCO2, ventilator & suction Circulation - lines, “uppers”, monitoring Disability - sedation, paralysis, neuro protection Exposure - Blankets, other injuries Fluids – crystallloid, hypertonics, blood, electrolytes, catheterise Gut - ?NG, antiemetics Haematology – FBC/U&Es/Clotting/G&S Imaging & Notes Journal - transfer documents Organisational Kit – transfer bag, pumps, power cables, monitor Location (phone numbers / contact) Money Nourishment Outdoor protection Phone Ready to ….