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Treating Elevated ICP in the TBI Patient. Andrew Asimos, MD Director of Emergency Stroke Care Neuroscience and Spine Institute Carolinas Medical Center, Charlotte, NC Adjunct Associate Professor, Department of Emergency Medicine University of North Carolina School of Medicine at Chapel Hill.

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Andrew Asimos, MDDirector of Emergency Stroke CareNeuroscience and Spine InstituteCarolinas Medical Center, Charlotte, NCAdjunct Associate Professor, Department of Emergency MedicineUniversity of North Carolina School of Medicine at Chapel Hill

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Attending PhysicianEmergency MedicineCarolinas Medical CenterDepartment of Emergency MedicineCharlotte, NC
session objectives
Session Objectives
  • Present a relevant patient case
  • State key clinical questions
  • Outline the procedure for treating elevated ICP
clinical history
Clinical History
  • 18 year old male non-helmeted skateboarder, struck his head on driveway
  • Closest L1TC one hour by helicopter
  • Being taken to non-trauma center ED
  • Prehospital care: IV, O2 via NRB mask, monitor
  • Intermittently combative
  • Attempting immobilization
physical exam
Physical Exam
  • 98.8 100/60 110 12 pulse ox 95%
  • Gen: Intermittently agitated
  • Head: Scalp abraisions, soft tissue selling over R temporal-parietal region, hemotympanum
  • Face: Several abrasions
  • Eyes: 4 mm, equal, reactive
physical exam9
Physical Exam
  • Chest: BSBE, no crepitus
  • Cardiac: Tachycardia without murmur
  • Abd: Soft, FAST negative
  • Pelvis: Stable to compression
  • Ext: No long bone deformity, abrasions
neurologic exam
Neurologic Exam
  • Motor: Withdraws to painful stimuli, no posturing, no pathological reflexes
  • Eyes: Open to painful stimuli, PERL
  • Verbal: Perseverating speech
  • Sensory: No sensory level
provisional diagnosis
Provisional Diagnosis
  • Moderate to Severe TBI
    • GCS Score ≈ 9-10
key clinical questions
Key Clinical Questions
  • In the setting of acute TBI, what are the clinical signs and symptoms of increased ICP?
  • What imaging findings suggest impending herniation syndrome in the TBI patient?
  • How should patients with suspected increased ICP in the setting of TBI be managed?
  • What are the roles for the following therapies in the setting of suspected increased ICP: mannitol, hyperventilation, steroids, seizure prophylaxis, and skull trephination?
icp detection pearls
ICP Detection Pearls
  • VS don’t change until late in the clinical course of increased ICP and herniation
  • Signs and symptoms of increased ICP in TBI
    • GCS score of 8 or less
    • Decreased level of consciousness
    • Cranial nerve findings
      • Eye exam is key
    • CT scans showing ventricle or cistern abnormalities, or midline shift
brain herniation
Brain Herniation
  • Cranial contents compartmentalized by a layering of dura mater
    • Folding dura forms distinct brain compartments
      • Falx cerebri – separates 2 hemispheres
      • Tentorium cerebelli – separates infratentorial structures from supratentorial structures
  • Expansion of IC contents limited by skull and these compartments
transtentorial herniation
Transtentorial Herniation
  • Brain traverses tentorium at the level of the incisura
  • Divided into
    • Descending
      • Largest category
      • Mass effect in the cerebrum pushes supratentorial brain through incisura to the posterior fossa
    • Ascending
      • Mass effect in posterior fossa leads to brain extending through the incisura in an upward
central transtentorial herniation
Central Transtentorial Herniation
  • Causes
    • Diffuse and severe TBI swelling
    • Centrally located, supratentorial masses
      • Thalamic hemorrhage
    • Lesions of the frontal, parietal, & occipital lobes
  • Downward movement of the diencephalon and rostral midbrain through the tentorial notch
diagnosing central transtentorial herniation
Diagnosing Central Transtentorial Herniation
  • Progressive rostrocaudal deterioration of brainstem function
    • Compression of diencephalic structures causes lethargy, apathy, or confusion
    • Loss of upward gaze due to compression of the diencepahlic pretectal area against the posterior tentorial incisura
    • Extensor plantar responses, paratonia, ipsilateral decortication, contralateral decerebration
    • Pupils dilate to midposition because of sympathetic and parasympathetic dysfuction
    • Hyperventilation
    • Decerebrate rigidity
    • Autonomic dysregulation
  • VS do not change until late
uncal herniation
Uncal Herniation
  • Associated with supratentorial masses and masses in the temporal fossa
    • Subdural or epidural hematoma, large MCA stroke, temporal lobe tumor
  • Medial portion of the temporal lobe (uncus) displaces over the tentorial notch
  • Causing compression of
    • Ipsilateral oculomotor nerve and brainstem compression
    • Occasionally the ipsilateral PCA
diagnosing uncal herniation
Diagnosing Uncal Herniation
  • Classically, a stepwise progression
    • Early clinical sign is dilatation of the ipsilateral pupil
      • Compression of the parasympathetic fibers traveling on the periphery of the third nerve
    • Loss of the light reflex, ipsilateral ptosis, “down and out” eye
      • Patient may be surprisingly alert
    • Contralateral hemiparesis
      • Compression of the ipsilateral cerebral peducle against the free edge of the tentorium
      • Rarely ipsilateral hemiparesis (Kernohan’s phenomenon)
    • Consciousness deteriorates
      • Midbrain compession, sometimes associated hemorrhage, with compromise of the ascending portion of the RAS
    • Bilateral pupillary dilation
  • Changes in VS may not occur until just prior to fatal herniation
    • Respiratory changes and bradycardia
imaging findings of uncal herniation
Imaging Findings of Uncal Herniation

Usual six pointed star appearance of the suprasellar cistern

Truncated suprasellar cistern on the ipsilateral side of the herniation

featured procedures or protocols
Featured Procedures or Protocols
  • Treatment protocol for the management of elevated intracranial pressure (ICP)
  • Skull trephination for the management of suspected uncal herniation due to an expanding epidural hematoma
btf guidelines for the management of severe traumatic brain injury
BTF Guidelines for the Management of Severe Traumatic Brain Injury

Management and

Prognosis of Severe

Traumatic Brain Injury

Brain Trauma Foundation, Inc, American Association of Neurological Surgeons. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

btf tbi treatment guidelines
BTF TBI Treatment Guidelines
  • Head Injury Guidelines Task Force (AANS)
    • Initial draft 2000, revision due 2006
  • Key Concept
    • Evidence based TBI treatment guidelines exist and are widely available

Brain Trauma Foundation, Inc, American Association of Neurological Surgeons. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

elevated icp rx procedure
Elevated ICP Rx Procedure
  • Evaluate globally all resuscitation needs
initial management
Initial Management
  • No Standards or Guidelines
  • Options
    • Complete and rapid physiologic resuscitation
    • No specific treatment for intracranial hypertension in the absence of signs of transtentorial herniation or progressive neurologic deterioration not attributable to extracranial explanations

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

hypoxia and hypotension in tbi
Hypoxia and Hypotension in TBI

Chesnut RM et al. J Trauma 34(2):216-22, 1993 Feb.

elevated icp rx procedure36
Elevated ICP Rx Procedure
  • Evaluate globally all resuscitation needs
  • Do not provide prophylactic osmotherapy
    • Only with clinical deterioration
  • Do not use prophylactic hyperventilation
mannitol
Mannitol
  • Standards
    • There are insufficient data to support a treatment standard for the use of mannitol
  • Guidelines
    • Mannitol is effective for control of raised ICP after severe head injury
    • Effective doses range from 0.25 g/kg body weight to 1 gm/kg body weight

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

mannitol38
Mannitol
  • Options
    • The indications for the use of mannitol prior to ICP monitoring are signs of transtentorial herniation or progressive neurological deterioration not attributable to extracranial explanations
    • Avoid hypovolemia by fluid replacement
  • Intermittent boluses may be more effective than continuous infusion

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

mannitol39
Mannitol
  • Appropriate dosing range in the ED is 0.25-1.4 g/kg administered “wide open”
  • The Cochrane Review concludes high-dose mannitol (1.4 g/kg) appears to be preferable to conventional-dose mannitol in the pre-operative management of patients with acute intracranial hematomas

Roberts I et al. Mannitol for acute traumatic brain injury. Cochrane Injuries Group Cochrane Database of Systematic Reviews 2005.

elevated icp rx procedure40
Elevated ICP Rx Procedure
  • Evaluate globally all resuscitation needs
  • Do not provide prophylactic osmotherapy
    • Only with clinical deterioration
  • Do not use prophylactic hyperventilation
    • Only with clinical deterioration
hyperventilation
Hyperventilation
  • Standards
    • In the absence of increased ICP, chronic prolonged hyperventilation therapy (PaCO2 <25 mm Hg) should be avoided after severe traumatic brain injury
  • Guidelines
    • The use of prophylactic hyperventilation (PaCO2 <35 mm Hg) therapy during the first 24 hours after severe traumatic brain injury should be avoided because it can compromise CPP during a time when CBF is reduced

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

hyperventilation42
Hyperventilation
  • Options
    • Hyperventilation therapy may be necessary for brief periods
      • When there is acute neurologic deterioration
    • For longer periods if there is intracranial hypertension refractory to sedation, paralysis, cerebrospinal fluid drainage, and osmotic diuretics

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

elevated icp rx procedure43
Elevated ICP Rx Procedure
  • Evaluate globally all resuscitation needs
  • Do not provide prophylactic osmotherapy
    • Only with clinical deterioration
  • Do not use prophylactic hyperventilation
    • Only with clinical deterioration
  • Consider seizure prophylaxis
seizure prophylaxis
Seizure Prophylaxis
  • Standards
    • Prophylactic use of phenytoin, carbamazepine, phenobarbital or valproate is not recommended for preventing late post-traumatic seizures
  • Guidelines
    • None

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

seizure prophylaxis45
Seizure Prophylaxis
  • Options
    • It is recommended as a treatment option that anticonvulsants may be used to prevent early post-traumatic seizures in patients at high risk for seizures following head injury
    • Phenytoin and carbamazepine have been demonstrated to be effective in preventing early post-traumatic seizures
    • Available evidence does not indicate that prevention of early post-traumatic seizures improves outcome following head injury

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

elevated icp rx procedure46
Elevated ICP Rx Procedure
  • Evaluate globally all resuscitation needs
  • Do not provide prophylactic osmotherapy
    • Only with clinical deterioration
  • Do not use prophylactic hyperventilation
    • Only with clinical deterioration
  • Consider seizure prophylaxis
  • Do not use steroids
steroids
Steroids
  • Standards
    • The use of steroids is not recommended for improving outcome or reducing ICP in patients with severe TBI
  • Guidelines
    • None
  • Options
    • None

Brain Trauma Foundation, Inc, AANS. Guidelines for the Management of Severe Traumatic Brain Injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

steroids48
Steroids
  • Conclusions
    • In the absence of a meta-analysis, we feel most weight should be placed on the result of the largest trial
    • The increase in mortality with steroids in this trial suggest that steroids should no longer be routinely used in people with traumatic head injury

Alderson P, Roberts I. Corticosteroids for acute traumatic brain injury. Cochrane Injuries Group Cochrane Database of Systematic Reviews 2005.

indications for emergent cranial decompression
Indications for Emergent Cranial Decompression
  • To evacuate extradural hematomas
  • To reverse clinical signs of tentorial herniation
  • Rapid, progressive neurologic deterioration
  • Timely inavailability of a neurosurgeon
emergent cranial decompression the procedure
Emergent Cranial Decompression:The Procedure
  • 4 cm vertical incision
  • External auditory canal is key landmark
    • Three cm superior to zygoma
    • Two cm anterior to ear
emergent cranial decompression the procedure52
Retract the scalp and galea

May hit the superficial temporal artery

Cut through the temporal fascia and temporal muscle

Retract with a Weitlaner retractor

Emergent Cranial Decompression:The Procedure
emergent cranial decompression the procedure53
Emergent Cranial Decompression:The Procedure
  • Drill a hole, enlarge with a Burr
  • Careful as the inner table is perforated
  • Epidural hematoma will likely have a jelly consistency
  • Middle meningeal artery is deep to clot
  • Foramen spinosum transmits middle meningeal artery
emergent cranial decompression the procedure54
Emergent Cranial Decompression:The Procedure
  • Be prepared to replace blood loss
  • If no CT prior and bilateral fixed pupils or no clot, consider repeating on contra-lateral side
ed patient management
ED Patient Management
  • Patients RSI’d, paralyzed and sedated for emergenct CT scanning
  • CT scan indicates a right temporal epidural hematoma
  • Aeromedically evacuated to a L1TC
  • On arrival to L1TC, right pupil noted to be dilated, ABG on arrival with pCO2 39
  • Bolused with 1.4 gm/kg Mannitol
  • Ventilatory rate increased, TV unchanged
  • Emergently taken to OR for hematoma evacuation
patient outcome
Patient Outcome
  • Hematoma evacuated without difficulty
  • Three day ICU stay
  • Minimal cognitive deficits on hospital discharge
  • No motor deficits
treating elevated icp in the tbi patient59
Treating Elevated ICPin the TBI Patient
  • Know the clinical and CT signs of elevated ICP
  • Know the treatment guidelines
  • If a neurosurgical intervention is anticipated, know its relative availability
  • If a heroic procedure is the only option, know its basic steps, gather required equipment, and utilize any consultants possible