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Management Of High I C P And Traumatic Brain Injury

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Andrew Ferguson
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Management of Traumatic Head Injury ,[object Object]
Objectives ,[object Object],[object Object],[object Object],[object Object]
Neurophysiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Management of Head Injury Emergency Diagnostic or Therapeutic Procedures Tracheal Intubation Fluid Resuscitation Ventilation/Oxygenation Sedation Severe Head Injury GCS≤8 ATLS Trauma Evaluation Deterioration Herniation CT Scan ICU ± Hyperventilate ± Mannitol Surgical Drainage
Management of Raised ICP ,[object Object],Raised ICP>25mm Hg Measure ICP Maintain CPP>70 mm Hg Ventricular Drain Elevate HOB Normal Vent/Oxygenation Mannitol Sedation Raised ICP>25mm Hg CT
Management of Raised ICP ,[object Object],Raised ICP>25mm Hg Maintain CPP>70 mm Hg Furosemide Chemical Paralysis CSF Removal Vasopressor Barbiturates Hyperventilation Monitor S j O 2 Raised ICP>25mm Hg
Head Injury ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Role of ICP Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],CPP=MAP-ICP
ICP Monitors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ICP Monitors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of Traumatic Brain Injury Hypothermia Hypertonic Saline Neuro-protection Other Issues BP and Oxygen Indications for ICP CPP Mannitol Barbiturates Hyperventilation Glucocorticoids Guidelines Standards BTF and AANS Guidelines Process
AANS & BTF Head Injury Guidelines (2000) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hyperventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hyperventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],N= 77
Xenon Perfusion CBF PCO 2 = 45 torr ICP = 44 mmHg CBF = 59 mL/min/100 gm PCO 2 = 30 torr ICP = 15 mmHg CBF = 14 mL/min/100 gm Skippen P et al: Crit Care Med 1997; 25:1402-1409
Use of Hyperventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Glucocorticoids ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CRASH Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lancet 2004; 364: 1321-38
Glucocorticoids in Severe Head Injury ,[object Object],[object Object]
Blood Pressure and Oxygenation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Death Chesnut et al 1997 Pietropaoli et al 1992 Outcome %
Blood Pressure and Oxygenation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rational for ICP Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],Narayan et al 1982
Intracranial Pressure Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Does ICP Monitoring Improve Outcome ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Groups managed at different time periods Other confounding factors
Does ICP Monitoring Improve Outcome ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cerebral Perfusion Pressure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Physiology ,[object Object],[object Object],[object Object]
Cerebral Perfusion Pressure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Guidelines for Cerebral Perfusion Pressure ,[object Object],[object Object],[object Object],[object Object]
Mannitol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mannitol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mannitol Use in Severe Head Injury ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Barbiturates ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Barbiturates ,[object Object],[object Object],[object Object]
Schwartz et al (1984) ,[object Object],[object Object],N=59 Mortality
Eisenberg et al (1988) ,[object Object],[object Object],[object Object],[object Object],ICP Control %
Barbiturate Use in Severe Head Injury ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hypothermia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Temperature Control and Induced Hypothermia ,[object Object],[object Object],[object Object],[object Object]
NABISH Results NEJM 2001; 344: 556-63 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
But Food for Thought… ,[object Object],[object Object],[object Object],[object Object],[object Object]
Hypertonic Saline ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
SAFE trial ,[object Object],[object Object],[object Object],[object Object]
Other stuff to consider ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object]

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Management Of High I C P And Traumatic Brain Injury

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  • 5. Management of Head Injury Emergency Diagnostic or Therapeutic Procedures Tracheal Intubation Fluid Resuscitation Ventilation/Oxygenation Sedation Severe Head Injury GCS≤8 ATLS Trauma Evaluation Deterioration Herniation CT Scan ICU ± Hyperventilate ± Mannitol Surgical Drainage
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  • 12. Management of Traumatic Brain Injury Hypothermia Hypertonic Saline Neuro-protection Other Issues BP and Oxygen Indications for ICP CPP Mannitol Barbiturates Hyperventilation Glucocorticoids Guidelines Standards BTF and AANS Guidelines Process
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  • 16. Xenon Perfusion CBF PCO 2 = 45 torr ICP = 44 mmHg CBF = 59 mL/min/100 gm PCO 2 = 30 torr ICP = 15 mmHg CBF = 14 mL/min/100 gm Skippen P et al: Crit Care Med 1997; 25:1402-1409
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