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Alyssa Morris, R4 August 12, 2010 Thanks to Dr Adam Oster
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Prehospital intubation of a head injury Anti-seizure prophylaxis Intubation of a head injury Premedication Induction agent Management of herniation Mannitol Hypertonic saline Cooling in TBI CT head rules
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27M restrained driver in a single vehicle MVA at highway speed. GCS 13, no obvious head trauma, other vitals stable, combative 26F restrained passenger in the rollover GCS 8, obvious lacerations and bleeding from scalp, BP 102/60, P= 110, 02 sats 94% RA
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Objective: determine if ALS care in field for trauma patients improves morbidity and mortality Design: Before-after clinical trial Population: n= 2867, trauma pts >16y.o, severity score>12 Results: (ALS v. BLS) Overall Survival 81.1% v. 81.8% (p=0.65) Survival in GCS<9 50.9% v. 60.0% (p=0.02)
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The patients are now in the ED. 27M GCS 14 one hour after exam, no obvious amnesia, slightly agitated, vitals stable and nothing else on exam. 26F GCS 8 obvious depressed skull fracture.
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1. Do you want to ask radiology for a CT head for these patients? 2. What were the outcomes the rule was predicting? 3. What are the High Risk criteria? 4. What are the Medium Risk criteria?
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Objective: develop a highly sensitive clinical decision rule for use of CT in pts w minor head injury Inclusion Criteria: blunt trauma to the head w witnessed LOC definite amnesia witnessed deterioration initial ED GCS >=13 injury w/i past 24h
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Exclusion Criteria <16y.o Minimal head injury No clear hx of trauma Penetrating skull injury Focal neuro deficit Unstable vital signs Had a seizure before ED assessment Bleeding disorder or anticoagulated pregnant
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High Risk (for neurological intervention) GCS < 15 at 2 hrs after injury Suspected open or depressed skull # Any sign of basal skull fracture Vomiting >= 2 episodes Age >= 65 Medium Risk (for brain injury on CT) Amnesia before impact >= 30 min Dangerous mechanism ▪ Pedestrian ▪ Ejected ▪ Fall from elevation >=3ft or 5 stairs
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The nurse asks if you want to give these patients dilantin to prevent a seizure given they have head injuries. The female reportedly has already had a seizure but the male has not. Q: Will you give dilantin to the 27M? Q: Will you give dilating to the 26F?
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6 randomized controlled trials included Results For every 100 pts treated with AEDs, 10 would be kept seizure free in 1 st week No reduction in mortality No reduction in neurological disability No reduction in late seizure onset Conclusion Does reduce early PTS but no outcome benefit No evidence to support routine use at any time after injury
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Practice Recommendations Prophylactic treatment with phenytoin, beginning with an IV loading dose, ASAP after injury should be used routinely to prevent early PTS Prophylactic treatment should not be used beyond first 7 days after injury
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Recommendations LEVEL I ▪ Insufficient data LEVEL II ▪ AEDs are indicated to decrease the incidence of early PTS (w/i 7d of injury). However, early PTS is not associated with worse outcomes. ▪ Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS
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Recommendations Standards ▪ Insufficient data Guidelines ▪ Prophylactic use of AEDs to prevent late PTS is not recommended Options ▪ Prophylactic use of AEDs to prevent early PTS may be considered as a treatment
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27M is becoming more combative and you are preparing to intubate him. Q: Will you premedicate? Q: What will you use for induction?
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1.5mg/kg 3 minutes before RSI No article answering our exact question Found 6 papers Benefit shown in: Brain neoplasms undergoing resection ETT suctioning (already intubated and Mx) No benefit or harm shown in: Prolonged decreased MAP (CPP= MAP-ICP) Has to be given minutes before RSI
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Objective: use swine model with ICP monitors in to monitor changes with different versions of RSI Groups: 1)Thiopental 2) Thiopental and Sux 3) Lido, Thiopental, Sux 4) pancuronium, lido, thiopental, sux
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Advocated for use in premedication Rosen’s AIME US airway course 3mcg/kg 3 minutes before No evidence from our setting or at time of ETI
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Objective: determine the effect of fentanyl on ICP in head injured sedated patients with monitors in place Design: randomized Results: Significant increase in ICP transiently Significant decrease in MAP Significant decrease in CPP
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Objective: determine the effect of fentanyl on ICP and CBF in sedated patients with severe head injury Design: Randomized Results: Significantly increased ICP Significantly decreased MAP No change in CBF
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The case against Ketamine 1. Gardner et al. Intracranial CSF pressure in man during ketamine. Anesth Analg. 1972;51:741-5. 2. Shapiro et al. Ketamine anesthesia in patients with intracranial pathology. Br J Anesth. 1972;44:1200-04. 3. Takeshita et al. The effects of ketamine on cerebral circulation and metabolism in man. Anesthesiology. 1972;36:69-75.
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Objective: determine effect of IV Ketamine on ICP/CPP/MAP Population: 8 ventilated patients with ICP monitors in place Intervention:1.5, 3 and 5mg/kg IV Results: Significant reduction in ICP
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Design: prospective double-blind RCT Population: 25 pts with severe head injury Intervention: continuous infusion of ketamine-midazolam v. sufentanil- midazolam Results No significant difference in daily ICP No significant change in daily CPP
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Design: prospective RCT Population: 35 patients with moderate or severe head injury Intervention: ketamine-midazolam v. fentanyl-midazolam infusions Results Slightly higher ICP in ketamine group (2mmHg) Slightly higher CPP in ketamine group (8mmHg)
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Increases ICP Old studies in patients with abnormal CSF flow Increases CPP ▪ Not sure of the effect this has on regional blood flow to penumbra and outcome assoc w this Neuroprotective NMDA R antagonist decreases glutamate (neurotoxic) ?neuroprotective Some animal models, nothing strong in humans
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Your patients are now both intubated. What are you initial vent settings and what goal(s) do you give the RT? If the patient shows evidence of herniation how does this change you approach to ventilation?
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Not Herniating Mode: AC Vt= 8cc/kg PEEP= 5 PCO2= 35-40 RR= 10-18 Herniating Hyperventilate until clinical recovery or definitive Mx
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LEVEL I Insufficient evidence LEVEL II Prophylactic hyperventilation (PaCO2 of 25) isnot recommended LEVEL III Hyperventilation is recommended as a temporizing measure for the reduction in elevated ICP
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STANDARDS Insufficient data GUIDELINES Insufficient data OPTIONS Mild hyperventilation (PCO2<35) should be avoided Mild hyperventilation may be considered for long periods of refractory high ICP Aggressive hyperventilation (PCO2<30) may be considered for brief periods in cases of cerebral herniation or acute neuro deterioration
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The female patient now has a blown pupil. How do you want to manage this?
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1. HYPEROSMOLAR THERAPY 1. Mannitol 2. Hypertonic Saline 3. Barbiturates 2. HYPERVENTILATION 3. SURGERY
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Objective: Compare high dose barbiturates to mannitol for ICP control Design: RCT Results: ICP significantly lowered in mannitol group CPP significantly improved Mortality improved
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Level I Evidence Insufficient data to support level I evidence Level II Evidence Mannitol is effective for control of ICP Dose of 0.25g/kg-1g/kg Avoid SBP<90 Level III Evidence Restrict to use in patients with signs of herniation OR w an ICP monitor in
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Design: Prospective Objective: effect 3% Saline continuous infusion on refractory elevated ICP in severe HI pediatric patients Results Statistically significant decrease in ICP Statistically significant decrease in # of ICP spikes Statistically significant increase in CPP
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Design: prospective RCT pilot Population: 9 patients with ICP>20 Intervention: 200cc bolus of 20% Mannitol v 100cc bolus of 7.5% Saline over 5 minutes Results: Significant reduction in ICP with HS compared to mannitol Both reduced ICP (13mmHg v 7.5mmHg)
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Current evidence is not strong enough to make recommendations on the use, strength and method of administration of hypertonic saline
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Standards Not enough evidence Guidelines ▪ Not enough evidence Options HS is effective for control of ICP after severe head injury ▪ 3% Saline 0.1mL/kg to 1.0mL/kg continuous Mannitol is effective for control of ICP after severe head injury ▪ 0.25-1.0g/kg bolus
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Your patients are now intubated, stable and ICU is rounding so want you to manage them for a few hours. The nurse asks if you want to cool the patients. Are you going to cool this patient?
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Design: large multicenter RCT Intervention: hypothermia (33C) initiated w/i 6 hrs for 48hrs v. normothermia Population: n= 362, age 16-65 with coma after CHI Results: (hypo v. normo) Poor functional outcome: 57% vs 57% Mortality: 28% vs 27% Fewer hypothermic patients had high ICP
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Design: multicenter, international, RCT Intervention: hypothermia (32.5C for 24hr w/i 8hrs of injury) v. normothermia (37C) Population: n= 225, Age 1-17 with TBI and GCS<8, CT w brain injury and need for mechanical ventilation Results: (hypo v. normo) Unfavorable outcome 31% v 22% P= 0.14 Deaths 23 v 14 P=0.06
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LEVEL I EVIDENCE Insufficient data LEVEL II EVIDENCE Insufficient data LEVEL III EVIDENCE Pooled data indicate hypothermia is not significantly associated with decreased mortality It is associated with significantly higher outcome scores Need to maintain for >48hrs
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STANDARDS Insufficient data GUIDELINES Insufficient data OPTIONS Extrapolated from adult data, hyperthermia should be avoided Despite lack of evidence, hypothermia may be considered in cases of refractory intracranial htn
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Maintain normothermia What if they are febrile?
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Intubate in field? CT head rules pocket guide AED prophylaxis? Premedication with lido/fentanyl? Induction with ketamine? In whom? Use of mannitol for herniation? Use of hypertonic saline for herniation? Vent strategies? Cooling?
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5M who fell off a chair and hit the temporal side of his head on the side of a table. No loss of consciousness. Next day vomits 6 times and complains of headache 7F falls from the Jungle Gym (7ft) and hits her head. No amnesia, no LOC, normal exam 18m.o. M fell from change table onto hardwood floor. Cried immediately. Has had a good feed but is slightly irritable when you examine him
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