1. Role of the Critical Care Surgeon in Traumatic Brain Injury Jon C. Krook, M.D., F.A.C.S. Department of Surgery HCMC

2. 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

3. Admission CT

4. Post-operative CT

5. Post-operative CT #2

6. 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

7. Outside Hospital CT

8. Outside Hospital CT PID#1

9. HCMC Arrival CT

10. Initial assessment

11. 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

12. 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

13. 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

14. General critical care concepts specific to the head injured patient

15. 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

16. Monro/Kellie Doctrine Brain Blood CSF

17. Herniation Supertentorial Herniation –1 Uncal (transtentorial) –2 Central –3 Cingulate (subfalcine) –4 Transcalvarial Infratentorial –5 Upward (upward cerebellar) –6 Tonsilar (downward cerebellar) http://en.wikipedia.org/wiki/Brain_herniation

18. Intracranial Pressure Monitoring Types –Bolt (subdural screw) –Epidural sensor –Ventriculostomy Diagnostic Therapeutic

19. Cerebral Perfusion Pressure CCP= MAP - ICP

20. 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

21. Lowering ICP Options –Sedation –Draining CSF –Hyperosmolar therapy

22. Triangle of ICU Sedation Analgesia Anxiolytics/Sedation Paralytics Delirium

23. 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

24. Sedation Fentanyl –Rapid onset, short duration of action –Usually given as a drip Some evidence of worsening of CCP (  BP,  ICP) with bolus

25. Hyperosmolar Therapy Mannitol –Osmotic diuretic –Can cause hypotension –Fairly quick onset Hypertonic saline –Osmotic diuretic –Does not cause hypotension –May increase CPP

26. 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

27. 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

28. Decompressive crainectomy Neurosurgical decision Violates the Monro-Kellie Doctrine

29. 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

30. 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

31. Steroids Only level I data from the Brain Trauma Foundation Guidelines is don’t use steroids

32. General Critical Care Concepts

33. 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

34. Ventilatory Management Most head injured patients have normal lungs –They don’t all stay that way

35. Ventilatory Management

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

37. Nutrition

38. 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

39. Other conditions Head injured patients are already complicated –Adding other injuries adds to the complexity Gatekeeper

40. Ethics Family discussions Difficult to predict level of long term impairment sometimes There can be fates worse than death Comfort Care

41. Case Presentation #1 Fixed and dilated pupils + Corneals and gag reflexes Withdraws upper extremities, flexion posturing lower extremities Intensive family discussions Comfort care

42. 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

43. Case Presentation #2

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

46. Questions?