1 / 51

Optimizing ED Management of Severe Traumatic Brain Injury: A Diagnosis & Treatment Protocol

Optimizing ED Management of Severe Traumatic Brain Injury: A Diagnosis & Treatment Protocol. Scott Weingart, MD Assistant Professor Director of ED Critical Care Elmhurst Hospital Center Mount Sinai School of Medicine New York, NY. Objectives. Improve pt outcome in TBI

whitby
Download Presentation

Optimizing ED Management of Severe Traumatic Brain Injury: A Diagnosis & Treatment Protocol

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. Scott Weingart, MDAssistant ProfessorDirector of ED Critical CareElmhurst Hospital CenterMount Sinai School of MedicineNew York, NY

  3. 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

  4. A Clinical Case

  5. Suspected TBI from trauma.org imagebank

  6. TBI Procedure Assess the GCS and Pupillary Response

  7. TBI Procedure Maintain MAP >90

  8. It’s all about Perfusion Since CPP=MAP – ICPand ICP is assumed to be elevated; we must maintain MAP to maintain CPP.

  9. TBI Procedure Maintain Sat >95%

  10. TBI Procedure Intubate if the GCS<9 or you suspect the patient may decompensate

  11. Neuroprotective Intubation • Pretreatment Meds • Lidocaine • Fentanyl • Defasiculating Dose Paralytic • MAP Stable Dose of Sedative • Paralytic • Skilled Intubater

  12. TBI Procedure Avoid Prophylactic Hyperventilation:Keep CO2 between 35-38

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

  14. Signs of Increasing ICP • Unilateral or bilateral unreactive, dilated pupil • Extensor posturing (decerebrate) • A sharp decline in GCS

  15. TBI Procedure Mannitol1.2-1.4 g / kg

  16. Confirmed TBI

  17. TBI Procedure Continue to Maintain MAPContinue to Maintain SatsContinue to Maintain CO2

  18. TBI Procedure Introduce the patient to a Neurosurgeon

  19. TBI Procedure Monitor ETCO2

  20. ETCO2 Keep PaCO2between 35-38:Treat EtCO2 >35

  21. TBI Procedure Push Na to ~150Never < 140

  22. Na in Resus Fluids

  23. TBI Procedure Head of the Bed to 45°

  24. TBI Procedure Temp <100° F

  25. TBI Procedure Serum Osm < 320

  26. TBI Procedure Monitor Urine Output:Keep Fluid Balance +

  27. TBI Procedure Administer Adequate Sedation &Pain Control

  28. TBI Procedure Early AppropriateICP Monitoring

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

  30. 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.

  31. ICP Monitoring CPP=MAP – ICPKeep ICP < 20Keep CPP > 60

  32. TBI Procedure Treat ↑ ICP

  33. ICP Treatment Mannitol Boluses:1 g / kg over ~ 10 minutesReplace all Urinary Output

  34. ICP Treatment Hypertonic Saline:250 cc 3% over ~ 10 minutes

  35. TBI Procedure Treat ↓ CPP

  36. CPP Treatment FluidsBloodInotropesPressors

  37. TBI Procedure Dilantin Load:20 mg/kg over 1 hour

  38. TBI Procedure Admit to a NeuroCriticalCare Bed

  39. 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

  40. Further Reading Guidelines for the Management and Prognosis of Severe Traumatic Brain Injury. http://www.braintrauma.org International Trauma Forum. http://www.trauma.org

More Related