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Management of Head Injury and Increased ICP

Management of Head Injury and Increased ICP. Nicole Baier , MD. Objectives. Review the: Epidemiology of head injury Various intracranial lesions Pathophysiology of increased ICP Management of head injury. Epidemiology. 2 cases per 1000 children per year Mild TBI: 82%

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Management of Head Injury and Increased ICP

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  1. Management of Head Injury and Increased ICP Nicole Baier, MD

  2. Objectives • Review the: • Epidemiology of head injury • Various intracranial lesions • Pathophysiology of increased ICP • Management of head injury

  3. Epidemiology • 2 cases per 1000 children per year • Mild TBI: 82% • Moderate to severe TBI: 14% • Fatal TBI: 5% (7000 deaths per year)

  4. Etiology • Motor vehicle accidents • Falls • Non-accidental trauma • Sports injuries

  5. Mechanisms of injury • Coup contusion • Adjacent to the site of injury • Brain accelerates against the fixed skull • Injury to parenchyma and blood vessels • Contrecoup contusion • Deceleration and recoil of the brain • Contralateral lesions

  6. Epidural Hematoma • Classic: arterial origin, blood collects between skull and dura

  7. Subdural Hematoma • Due to tearing of bridging veins, blood collects between dura and cortex

  8. Subarachnoid hemorrhage • Disruption of small vessels on the cortex, occur along the falx, tentorium, or outer cortical surface

  9. Intraventricular Hemorrhage

  10. Mechanisms of Injury • Axonal injury: • Etiology: deceleration and shearing forces • Axonal swelling and degeneration • CT findings: • Normal initially • Delayed edema and petechial hemorrhages • Areas affected: • Basal ganglia • Thalamus • Deep hemispheric nuclei • Corpus callosum

  11. Mechanisms of Injury

  12. Diffuse Axonal Injury

  13. Cerebral Edema • Cytotoxic Edema • Intracellular swelling • Due to cellular injury (DAI, hypoxia-ichemia) • Irreversible • Vasogenic Edema • Increased endothelial permeability • Therapy may prevent secondary injury • Seen with tumors, hematomas, infarcts, CNS infections • Interstitial Edema • Increased fluid in periventricular white matter • Etiology -  hydrostatic CSF pressure

  14. Monro-Kellie Doctrine • Intracranial Volume = Brain + CSF + Blood • Normal: • Brain 80% • CSF 10% • Blood 10%

  15. Monro-Kellie Doctrine

  16. ICP and intracranial volume

  17. Secondary injury • Bleed/edema increases intracranial volume → • Compress intracranial vessels → • Impairs blood flow → • Ischemia

  18. Cerebral perfusion pressure • CPP = MAP – ICP • > 70 in adults • Children ????

  19. What is Cushing’s Triad? • Hypertension, tachycardia, and dilated pupils • Hypotension, bradycardia, and posturing • Hypertension, bradycardia, and dilated pupils • Hypertension, bradycardia, and irregular respirations • Hypotension, tachycardia, and posturing

  20. Cushing’s Triad • Hypertension • Bradycardia • Irregular respirations • Etiology: • When MAP < ICP, the hypothalamus stimulates sympathetic output • Increase in BP stimulates carotid baroreceptors and leads to a vagal response and bradycardia

  21. A 2 year old boy is brought in by EMS. He was playing outside at home when a van backed into the driveway and ran over him. He was minimally responsive at the scene required bag-mask ventilation on the way in. You cannot elicit any response from him with painful stimulation. What is his GCS? • 2 • 3 • 4 • 5 • 6

  22. Glasgow Coma Score • Eyes: Motor: • 4 opens spontaneously - 6 follows commands • 3 opens to verbal command - 5 localizes pain • 2 opens to pain - 4 withdraws to pain • 1 no response - 3 decorticate • Verbal: - 2 decerebrate • 5 oriented - 1 no response • 4 confused conversation • 3 inappropriate words • 2 incomprehensible sounds • 1 no response

  23. Head Injury - grading • Mild: GCS ≥ 13 • Moderate: 9-12 • Severe: ≤8 Battle’s sign

  24. You decide to intubate the child. Which of the following medications would be contraindicated in the given scenario? • Etomidate • Lidocaine • Fentanyl • Succinylcholine • Rocuronium

  25. Management - Airway • Indications for intubation: • GCS ≤ 8 • Hypoxia • Loss of airway protective reflexes • Hypoventilation

  26. Management - Airway • Rapid sequence intubation: • C-spine stabilization • Preoxygenation • Cricoid pressure • Induction Meds: • Thiopental –  ICP ( cerebral metabolic rate) (may lower BP) or • Etomidate –  ICP or • Benzodiazepine (may lower BP) + • Opiate for analgesia for injuries/ laryngoscopy • +/- Lidocaine (may blunt  ICP assoc. with laryngoscopy) • Neuromuscular blockade

  27. The child was successfully intubated after premedication with lidocaine, fentanyl, etomidate, and rocuronium. None of his labs are back yet. However, you decide to institute therapy for increased ICP. Which of the following therapies is indicated at this point? • Insertion of an ICP monitor • 3% normal saline bolus • Mannitol • Hyperventilation to CO2 of 25-30 • Therapeutic hypothermia

  28. Management - Breathing • Try to keep CO2 normal (35-40) in patients with  ICP • Risk of ischemia with hyperventilation • Hyperventilation used only for acute herniation

  29. Management - Circulation • Maintain CPP to avoid secondary injury • Hypoxemia and hypotension each occur in 1/3 of patients • 1 episode of hypotension  mortality 2x • Eval source of shock: • Internal bleeding? • Spinal cord injury?

  30. Monitoring ICP • Indications: • GCS ≤ 8 • Neuro exam impossible (sedated, needs to go to OR for other injuries • Types: • Ventriculostomy most reliable, also therapeutic • Intraparenchymal – measurement drift • Subarachnoid, subdural, epidural – less reliable

  31. Head positioning • Head midline • Head of bed to 30 degrees • Promote venous drainage

  32. Sedation/ Analgesia • Benefits: • Decrease cerebral metabolic demands associated with pain and stress • Prevent spikes in ICP that may occur with suctioning, etc. • Facilitate mechanical ventilation • Anticonvulsant and antiemetic actions • Prevent shivering

  33. Neuromuscular blockade • Benefits: •  airway and intrathoracic pressure – facilitate cerebral venous outflow • Prevent shivering and posturing • Facilitate mechanical ventilation

  34. Which of the following statements about the use of 3% normal saline is true? • Can only be given through a central venous line • Does not cause hypotension • Can only be used if serum osmolarity < 320 • Dose is 10 mL/kg • Can only be used if serum sodium is < 160

  35. Hyperosmolar Therapy • 3% normal saline • Creates osmotic gradient • Decreases ICP and increases CPP • Used as boluses and/or continuous infusion • Goal: serum sodium > 150 • Max serum osm: 360 ??

  36. Hyperosmolar Therapy • Mannitol • Mechanisms: •  blood viscosity • creates osmotic gradient between plasma and brain • 0.25-1 g/kg doses • May repeat every 6-8 hours • Max serum osm: 320 • Adverse effects: • ATN • Hypovolemia

  37. CSF Drainage • Ventriculostomy catheter

  38. Which of the following statements regarding the use of pentobarbital is false? • Continuous EEG monitoring should be present when a pentobarbital coma is induced • The hallmark of pentobarbital coma is burst suppression • Pentobarbital causes profound myocardial depression • Pentobarbital use requires the approval of a neurologist • Pentobarbital reduces cerebral blood flow

  39. Barbiturate Coma • Consider in: • Patients with refractory intracranial hypertension • Mechanisms: • Lowers resting cerebral metabolic rate by 50% • Decreases cerebral blood flow and cerebral blood volume • Neuroprotective: inhibits free radical-mediated lipid peroxidation, stabilizes membranes

  40. Barbiturate Coma • Monitoring: • Burst suppression on EEG • Adverse effects: • Myocardial depression

  41. Thermoregulation • Avoid hyperthermia • Increase cerebral metabolism • Inflammation • Lipid peroxidation • Excitotoxicity • Seizures

  42. Surgical management • Decompressive craniectomy • Favorable surgical outcomes: • Within 48hrs of injury • Secondary  GCS • Herniation • Unfavorable: • Unimproved GCS of 3 • Extensive secondary brain insults

  43. Nutrition • Begin by 72 hours • Full replacement by 7 days • Patients with injury have increased resting metabolism expenditure • Increased mortality when head injured patients not fed within 1 week

  44. Which of the following statements is true regarding the incidence of seizures in traumatic brain injury? • Antiepileptic medications decrease the incidence of late seizures • Children < 2yo have a lower risk of seizures • Most early seizures occur in the first 24 hours • Seizures do not affect the outcome of traumatic brain injury • All children with traumatic brain injury should be treated with antiepileptic medications until 1 week post-injury

  45. Antiseizure prophylaxis • Posttraumatic seizures • Early: within 7 days • Late: after 7 days • Adverse effects: • Increase brain metabolic demands • Increase ICP • Lead to secondary brain injury

  46. Antiseizure prophylaxis • Risk of seizures: • Early: • 20-39% incidence in severe TBI •  risk if low GCS • < 2 yrs have 3x greater risk • Majority occur within first 24 hours

  47. Antiseizure medications • Risk of seizures • Late: • 7-12% incidence in severe TBI • Increased incidence in depressed skull fracture • Relation to early seizures? • Prophylactic anticonvulsants do not affect incidence

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