1. Scott Weingart, MD Optimizing ED Management of Severe Traumatic Brain Injury: A Diagnosis & Treatment Protocol

2. Scott Weingart, MD Scott Weingart, MD Assistant Professor Director of ED Critical Care Elmhurst Hospital Center Mount Sinai School of Medicine New York, NY

3. Scott Weingart, MD

4. Objectives Improve pt outcome in TBI Minimize secondary injury of TBI patients Improve monitoring of TBI Improve treatment of TBI Improve knowledge of TBI prognosis Improve emergency medicine practice

5. Scott Weingart, MD A Clinical Case

8. Scott Weingart, MD Suspected TBI from trauma.org imagebank

9. Scott Weingart, MD Assess the GCS and Pupillary Response TBI Procedure

11. Scott Weingart, MD Maintain MAP >90 TBI Procedure

12. Scott Weingart, MD Since CPP=MAP – ICP and ICP is assumed to be elevated; we must maintain MAP to maintain CPP. Since CPP=MAP – ICP and ICP is assumed to be elevated; we must maintain MAP to maintain CPP. It’s all about Perfusion

13. Scott Weingart, MD Maintain Sat >95% TBI Procedure

14. Scott Weingart, MD Intubate if the GCS<9 or you suspect the patient may decompensate TBI Procedure

15. Scott Weingart, MD Pretreatment Meds Lidocaine Fentanyl Defasiculating Dose Paralytic MAP Stable Dose of Sedative Paralytic Skilled Intubater Neuroprotective Intubation

16. Scott Weingart, MD Avoid Prophylactic Hyperventilation: Keep CO 2 between 35-38 TBI Procedure

17. Scott Weingart, MD If pt is showing signs of impending herniation, we may hyperventilate to 30 for a brief period of time Hyperventilation

18. Scott Weingart, MD Unilateral or bilateral unreactive, dilated pupil Extensor posturing (decerebrate) A sharp decline in GCS Signs of Increasing ICP

19. Scott Weingart, MD Mannitol 1.2-1.4 g / kg TBI Procedure

20. Scott Weingart, MD Confirmed TBI

21. Scott Weingart, MD Continue to Maintain MAP Continue to Maintain Sats Continue to Maintain CO 2 TBI Procedure

22. Scott Weingart, MD Introduce the patient to a Neurosurgeon TBI Procedure

23. Scott Weingart, MD Monitor ETCO 2 TBI Procedure

26. Scott Weingart, MD Keep PaCO 2 between 35-38: Treat EtCO 2 >35 ETCO 2

27. Scott Weingart, MD Push Na to ~150 Never < 140 TBI Procedure

28. Scott Weingart, MD NaClmOsm/L NS154 308 LR130109273 Na in Resus Fluids

29. Scott Weingart, MD Head of the Bed to 45° TBI Procedure

30. Scott Weingart, MD Temp <100° F TBI Procedure

31. Scott Weingart, MD Serum Osm < 320 TBI Procedure

32. Scott Weingart, MD Monitor Urine Output: Keep Fluid Balance + TBI Procedure

33. Scott Weingart, MD Administer Adequate Sedation & Pain Control TBI Procedure

34. Scott Weingart, MD Early Appropriate ICP Monitoring TBI Procedure

35. Scott Weingart, MD GCS (3-8) with abnormal head CTs GCS (3-8) with normal CTs and two of the following: SBP<90 Posturing Age>40 ICP Monitor Indications

39. Blaivas M et al. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med. 2003 Apr;10(4):376-81.

41. Scott Weingart, MD CPP=MAP – ICP Keep ICP 60 ICP Monitoring

42. Scott Weingart, MD Treat ↑ ICP TBI Procedure

43. Scott Weingart, MD Mannitol Boluses: 1 g / kg over ~ 10 minutes Replace all Urinary Output ICP Treatment

44. Scott Weingart, MD Hypertonic Saline: 250 cc 3% over ~ 10 minutes ICP Treatment

45. Scott Weingart, MD Treat ↓ CPP TBI Procedure

46. Scott Weingart, MD Fluids Blood Inotropes Pressors CPP Treatment

47. Scott Weingart, MD Dilantin Load: 20 mg/kg over 1 hour TBI Procedure

48. Scott Weingart, MD Admit to a NeuroCritical Care Bed TBI Procedure

49. Scott Weingart, MD Patient Outcome Decompressive Craniectomy Decompressive Laparotomy 4 Weeks In NTICU Received Tracheostomy Weaned off Vent Transferred to Floor Intensive OT/PT/Psych Support Came to visit at 7 months—Fully Intact

50. Scott Weingart, MD Further Reading Guidelines for the Management and Prognosis of Severe Traumatic Brain Injury. http://www.braintrauma.orghttp://www.braintrauma.org International Trauma Forum. http://www.trauma.org http://www.trauma.org

51. Scott Weingart, MD Questions?? www.ferne.org ferne@ferne.org Scott Weingart, MD Questions?? www.ferne.org ferne@ferne.org Scott Weingart, MD gatsby@eudoramail.com 817.977.3384 www.ferne.org Ferne_2006_aaem_sa_weingart_bic_spine.ppt