1. Traumatic Brain Injury DR.MALAV SHAH
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

2. TBI – learning objectives
Secondary brain injury
Early assessment & resuscitation
Cervical spine clearance & immobilization
Brain imaging
Indications, timing, inference
ICP control & critical care
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

3. Secondary brain injury
Intra & extra-cranial causes
Intra-cranial
Primary insult, cellular cascade, cerebral edema, seizures, intra-cranial infections,
Extra-cranial
Hypotension, hypoxia, hypercarbia, pain, fever, systemic infection
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

4. Consequences Increase ICP, decrease CPP & CBF
Leads to cerebral ischemia, herniation, cell death
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

5. Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

6. Management Early resuscitation as per ATLS Targets
Cervical spine clearance & immobilization
General measures
Craniotomy – if indicated
ICP measurement & management
Other measures
AED, sugar control
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

7. Early resuscitation Care during intubation
ABC to be assessed & fixed
Care during intubation
Maintain
MAP >70-80, auto-regulation affected
Saturation > 94, PaO2 >60
PaCO
If GCS is dropping or pupillary dilatation :
Elevate head, hyperventilate & hyperosmolar therapy
CT brain – once stable
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

8. General management Euvolemia, avoid hypervolemia & hypotonic fluids
Fluid management :
Euvolemia, avoid hypervolemia & hypotonic fluids
Hypertonic saline tried, avoid Albumin (SAFE study)
Sedation :
Reduces CMRO2, aids synchrony, reduces congestion
Drug selection individualized (Benzos, Narcotics, Propofol)
Propofol: Commonly used, <4mg/kg/hr, PIS
Complication: Hypotension & cerebral vasodilatation
Position : Head elevation & avoid venous congestion
Temperature : Euthermia
AED : Not as a routine, prophylactic in high risk group
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

9. Clearing cervical spine injury
Clinical
X-ray – AP, Lateral, Open mouth views
CT scan
MRI
Dynamic tests
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

10. Cervical spine protection
Collar – Philadelphia collar
Soft / hard collar – not useful
Lateral sand bags & forehead strap
For intubation - MILS
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

11. Indications of CT brain
GCS <8
Unequal pupil, seizures
Neurological deterioration
Mildly impaired consciousness persisting for few hours
Skull fracture
CSF leak
Penetrating injury
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

12. Craniotomy & evacuation
“Primary decompression”
For mass effect
Marshall CT grading
Volume/thickness (10,30,50)
Mass effect & Mid-line shift (>5)
Compressed basal cisterns
Low GCS
Depressed fracture
Penetrating injury
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

13. ICP management
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14. ICP monitoring – why? ICP needed to calculate CPP
ICP >20 & CPP <50 predict poor outcome
ICP needed to calculate CPP
Empirically boosting CPP may cause more harm
Allows for earlier initiation of therapy
Helps to monitor treatment responses
Can serve as a therapeutic modality
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

15. ICP monitoring – when? Or Abnormal CT
The guidelines for management of severe head injury recommends ICP monitoring in patients with GCS <8 and
Abnormal CT Or
Normal CT and any 2 of the following
Age >40
SBP <90
Unilateral or Bilateral Posturing
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

16. Management – Basic Good analgesia Perfusion – CPP 50-70
Oxygenation – 94
Normocarbia – 35-40
Normothermia
Good analgesia
If ICP continues to be high
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

17. EVD – Draining CSF Automatic drain, gravity dependent, manual drain
Can either monitor or drain
Various methods
Automatic drain, gravity dependent, manual drain
Keep 15 cm above tragus & keep it open or monitor
Manual drain
ICP >20 for >5 min, drain 1-2ml/min for 2-3 min, every 2-3 min till ICP is acceptable
Slow continuous passive gravitational drainage not well studied
Lumbar drain - contraindicated
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

18. Osmotherapy – Mannitol
Osmotic diuresis & reflex vasoconstriction
0.25-1gm/kg, 20%, over 15-20min, onset in 10 minutes, peak effect in min and lasts usually 4-6 hours (1-24 hrs)
Can be used with Furosemide to potentiate
Side effects : severe dehydration, hyponatremia, hypokalemia, renal failure, paradoxical cerebral edema
Hydration is needed
Increase renal toxicity when Sr. Osm >320
Use only as needed basis for ICP >20, Q8H
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

19. Osmotherapy – Hypertonic saline
Several studies shows Hypertonic NaCl can be used as a bolus / infusion to reduce ICP
Doses used vary widely from 1.6%, 3%, 250cc of 7.5% NaCL to 30cc of 23.4% NaCl over 15min
0.1-1ml/kg infusion of 3% - in paed. population
Contraindicated in hyponatremia
Monitor Na, renal functions
Accept Sr. osm upto 350
More useful in hypotensive & hypovolemic states
Has other benefits : prevents hyponatremia, membrane stabilization, immunomodulation
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

20. Osmotherapy-Mannitol Vs hypertonic saline
At least 5 RCT’s
In TBI, stroke, tumors
Hypertonic saline
More efficient in reducing ICP
But outcomes not examined
Need further studies
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

21. Hyperventilation Used for acute management
Maintain PaCO2 30 – 35
In refractory ICP raise, can reduce up to 26
Jugular bulb saturation & brain tissue O2 tension measurement helpful
Recommended by BTF guidelines
Can lead to severe vasocontriction & ischemia
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

22. Barbiturate Coma Thiopental or Pentobarbital
Suppresses brain metabolism and decreases CBF/ CBV
Titrated to seconds of burst suppression on EEG
Consistently controls ICP in refractory patients
No outcome benefits
Complications : Hypotension, sepsis
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

23. Hypothermia Increases VAP 32-34o C Systemic / local
Various meta-analysis
Reduces ICP but no significant mortality benefit
Increases VAP
Needs further better trials
Not recommended at this time
Can be used as rescue therapy in refractory cases
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

24. Decompressive craniectomy
“To give the swelling brain more space”
“Secondary decompression”
For raised ICP
Removing part of skull (B/l FTP) with dural opening
Craniectomy + Durotomy
In TBI : DECRA study
Bilateral FTP craniectomy
Maintains low ICP, shorter LOS
Same mortality
Low eGOS
Earlier DC may give better outcome?
RESCUEicp study report awaited
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

25. Seizure(PTS) prophylaxis
5-15 % incidence in TBI, 30% in severe TBI
High risk in – operated hematoma, penetrating injury, depressed fracture, focal signs, infection
Increases CBF, ICP, metabolic demand: leading to secondary brain injury
Status epilepticus, NCSE
Useful in the prevention of early PTS (<7 days)
Do not use long term
Phenytoin / Valproate / Carbamazepine
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

26. Other measures Arbitrary targets: INR < 1.4, Plt. > 75K
Glycaemic control:
Haemostatic therapy
Arbitrary targets: INR < 1.4, Plt. > 75K
Role of Xamic, Factor VII a
Steroids – worsens outcome
DVT prophylaxis
Ulcer prophylaxis
Neuroprotective agents
Citicoline, Magnesium, Progesterone, Erythropoietin
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

27. Summary – TBI Indications, timing, inference
Prevention of secondary brain injury
Early resuscitation – Oxygenation & perfusion
Brain imaging
Indications, timing, inference
Primary decompression - Craniotomy
ICP control & critical care
Analgesia, sedation, normocapnia, euthermia
ICP monitoring, EVD, CSF drainage
Hyperosmolar therapy, Hyperventilation
Sec. decompression, Barbiturate coma, Hypothermia
Supportive care, MMM
Ahmedabad | Bangalore | Chennai | Cuttack | Delhi | Erode | Hubli | Mysore | Mumbai | Nasik | Ongole | Pune | Ranchi | Shimoga | Uganda | Vijayawada

28. HCG Hospital at Ahmedabad, Gujarat
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