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

Admission CT

Post-operative CT

Post-operative CT #2

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

Outside Hospital CT

Outside Hospital CT PID#1

HCMC Arrival CT

Initial assessment

Initial evaluation of the Brain Injured Patient ATLS primary and secondary survey Avoid hypoxia and hypotension –Need to prioritize injury management ATLS Primary Survey AAirway BBreathing CCirculation DDisability EExposure

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 Blood CSF

Herniation Supertentorial Herniation –1 Uncal (transtentorial) –2 Central –3 Cingulate (subfalcine) –4 Transcalvarial Infratentorial –5 Upward (upward cerebellar) –6 Tonsilar (downward cerebellar)

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

Decompressive crainectomy 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

General Critical Care Concepts

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

Ventilatory Management

Infection prevention/treatment VAP prevention Catheter infection prevention Urinary catheter infection prevention Fever work ups –Five W’s Wind Water Wounds Walking Wonder Drugs

Nutrition

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

Case Presentation #2

Conclusions The Trauma Surgeon/Surgical Intensivist plays a core role in the care of the acute brain injured patient

Questions?