title: Traumatic Brain Injury author: "Callum Taylor" output: html_document: css: styles.css tags: notebook: ð-FFICM type: anki

Traumatic Brain Injury

References

Brain Trauma Guidelines ¹

SIBICC Traumatic Brain Injury Guidelines ²

Severe Traumatic Brain Injury Guidelines

Flashcard	type:basic
What are the two main guidelines to use for Traumatic Brain Injury?	SIBICC Guidelines (Seattle Brain Injury Consensus, 2019) Brain Trauma Foundation Guidelines (2016)

Flashcard	type:basic
What does SIBICC in SIBICC Guidelines stand for?	Seattle Brain Injury Consensus Guidelines
What year were SIBICC Guidelines released?	2019

SIBICC

These were consensus guidelines greated by a group of sTBI specialists (42 specialists - surgeons, neurologists, intensivists, emergency medicine from 6 continents).² So not strictly evidence based. It was written in response to the Brain Trauma Foundation Guidelines¹, which gave no algorithms, because they didn't have the evidence to support it.

Something made it into the recommendations if at least 80% of the people voting found it "acceptable".

They had a three tier system for managing ICP. As you go up the tiers you have higher risk interventions. ²

Flashcard	type:basic
How many tiers are in the SIBICC guidelines?	Four
The SIBICC Guidelines are to help you manage what particular aspect of what particular disease?	Aspect: Raised ICP Disease: Traumatic Brain Injury
What is the number for the lowest tier in the SIBICC Guidelines for Traumatic Brain Injury?	Zero
What type of ICU care is in Tier Zero of the SIBICC Guidelines for Traumatic Brain Injury?	Basic ICU Care
What is the number for the highest tier in the SIBICC Guidelines for Traumatic Brain Injury?	Three
What type of ICU care is in Tier Zero of the SIBICC Guidelines for Traumatic Brain Injury?	Most Invasive High Risk Interventions

Don't Do

Mannitol as continuous infusion
Scheduled hyperosmolar therapy
Lumbar CSF Drainage
Furosemide
Routine Steroids
Routine hypothermia < 35
High-dose propofol for burst suppression
Routine PaCO2 < 4 kPa
Routine CPP > 90 mmHg ²

Tiers

Flashcard	type:basic
What is raised ICP?	> 22mmHg

Flashcard	type:basic
What is satisfactory CPP? (Cerebral Perfusion Pressure)	> 60mmHg

Flashcard	type:basic
How do you calculate Cerebral Perfusion Pressure?	Mean Arterial Pressure - Intracranial Pressure

Tier Zero (Basic Care for Severe TBI regardless of ICP)

"The goal of Tier-zero is to establish a stable, neuroprotective physiologic baseline regardless of eventual ICP readings." ²

Must Do

Admit ICU
Intubate and Mechanical Ventilation
Serial assessment of neuro status + pupils
Elevate head of bed to 45 degrees
Analgesia for pain
Sedation for agitation/ventilation synch
Temperature (Prevent Fever)
Measure core temperature
Treat pyrexia (>38) ²

Should Do

Insert Central Line
ETCO2 Monitoring
Invasive BP Monitoring
Consider 1 Week Anti Epileptic Meds Prophylactic
Cerebral Perfusion Pressure >60mmHg
Haemoglobin > 7g/dL
Avoid Hyponatraemia
Optimise venous return
keep head midline
cervical collars not too tight
SpO2 > 94% ²

Flashcard	type:basic
Mechanical Ventilation starts in what tier of the SIBICC Guidelines?	Tier Zero - Basic ICU Care
Head Up 45 Degrees starts in what tier of the SIBICC Guidelines?	Tier Zero - Basic ICU Care
Analgesia and Sedation starts in what tier of the SIBICC Guidelines?	Tier Zero - Basic ICU Care
Preventing Pyrexia starts in what tier of the SIBICC Guidelines?	Tier Zero - Basic ICU Care
Central Line, Art Line, & CO2 Monitoring starts in what tier of the SIBICC Guidelines?	Tier Zero - Basic ICU Care
Prophylactic Antiepileptic Drugs (One Week) starts in what tier of the SIBICC Guidelines?	Tier Zero - Basic ICU Care
How long should you give antiepileptics for prophylactically in traumatic brain injury?	One week
What is the target SpO2 in Tier Zero of the SIBICC Guidelines?	> 94%
What is the target Hb in Tier Zero of the SIBICC Guidelines?	>70
What is the target CPP and MAP in Tier Zero of the SIBICC Guidelines?	CPP > 60 MAP > 80
What is the target Na in Tier Zero of the SIBICC Guidelines?	>130
Maintaining Na+ > 130 starts in what tier of the SIBICC Guidelines?	Tier Zero - Basic ICU Care

Guides For Tiers

Use lowest tier you can manage
Nothing in each tier is automatically the first thing to try
You don't need to do everything in a tier before trying the next
If it's obvious you need more you can skip a tier ²

If the tier isn't enough

Do they need a CT?
Do they need an operation?
Is there an extracranial cause?
Are the rest of the obs ok?
Do you need another expert? ²

Flashcard	type:basic
In traumatic head injury, you try one tier of management and it's not enough as ICP is still high, what five things should you do?	Ask do they need a CT Ask do they need surgery? Is there an extracranial cause? Are the rest of their obs ok? Go up a tier in management.

Tier One

CPP 60-70mmHg
Increase analgesia to lower ICP
Increase sedation to lower ICP
Target PaCO2 lower end of normal (4.7-5.1kPa)
Mannitol by intermittent bolus / Hypertonic saline by intermittent bolus
Consider EVD placement
CSF Drainage if EVD placed
Consider anti-seizure prophylaxis (for one week)
Consider EEG monitoring ²

Flashcard	type:basic
CPP targeting 60-70mmHg starts in what tier of the SIBICC Guidelines?	Tier One
Keeping PaCO2 4.7-5.1 starts in what tier of the SIBICC Guidelines	Tier One
What is the target PaCO2 in Tier One of the SIBICC Guidelines?	4.7-5.1
Mannitol by intermittent bolus starts in what tier of the SIBICC Guidelines?	Tier One
Hypertonic saline by intermittent bolus starts in what tier of the SIBICC Guidelines?	Tier One
EVD Placement and CSF Drainage starts in what tier of the SIBICC Guidelines?	Tier One
EEG monitoring starts in what tier of the SIBICC Guidelines?	Tier One

Tier Two

Target PaCO2 (4.3-4.6)
Neuromuscular Paralysis
Trial Dose First
- Only give continuous infusion if shown to work for ICP
There are risks of use, and some wanted it in tier three
MAP Challenge to assess cerebral autoregulation ²

Flashcard	type:basic
Keeping PaCO2 4.3-4.6 starts in what tier of the SIBICC Guidelines	Tier Two
What is the target PaCO2 in Tier Two of the SIBICC Guidelines?	4.3-4.6
Neuromuscular Paralysis starts in what tier of the SIBICC Guidelines?	Tier Two
MAP Challenge starts in what tier of the SIBICC Guidelines?	Tier Two
How do you give Neuromuscular Paralysis in Traumatic Brain Injury?	Give a trial dose See if it lowers ICP Only give continuous infusion if bolus lowered ICP

MAP Challenge

Increasing CPP (through increasing MAP) can decrease ICP when brain autoregulation is intact
If CPP is above "breakpoint" of autoregulation and you increase it further, you'll get intracerebral vasoconstriction (in an attempt to protect head pressure)
This means that blood flow to head reduces, which means that ICP reduces ²
If autoregulation is dirsupted (which it often can be in head injury) then increasing MAP, will increase CPP and there won't be any vasoconstriction, so you'll get more blood to head and higher ICP ²
Performing MAP Challenge
Increase vasopressor/inotrope to get MAP up by 10 for not more than 20 mins
Monitor MAP, CPP, ICP and PaO2
Adjust vasopressor/inotrope based on results
If MAP increase results in increasing ICP then autoregulation is disrupted, and you should not increase MAP
If MAP increase results in falling ICP, then autoregulation is intact, and you should go for a higher MAP ²

Flashcard	type:basic
What is the MAP Challenge in Traumatic Brain Injury attempting to answer?	Is cerebral autoregulation of pressure intact?
What would be the result of a MAP Challenge, in a patient who fails the challenge due to more severe traumatic brain injury?	As their MAP goes up, so does their CPP and their ICP
What would be the result of a MAP Challenge, in a patient who passes the challenge due to less severe traumatic brain injury?	As their MAP goes up, so does their CPP. So then they vasoconstrict the vessels in the head, which reduces the ICP
How much are you attempting to raise the MAP by, in the MAP challenge for Traumatic Brain Injury?	10mmHg
How long are you attempting to raise the MAP for, in the MAP challenge for Traumatic Brain Injury?	20mins
What criteria should you monitor when performing a MAP challenge in Traumatic Brain Injury?	MAP CPP ICP PaO2

Tier Three

Phenobarbitol/Thiopentone Coma
Only continue when achieves lowering ICP
Don't allow hypotension
Use burst suppression as target
Secondary decompressive craniectomy
Mild hypothermia (35-36) ²

Flashcard	type:basic
Mild hypothermia starts in what tier of the SIBICC Guidelines?	Tier Three
Phenobarbitol Coma starts in what tier of the SIBICC Guidelines?	Tier Three
Thiopentone Coma starts in what tier of the SIBICC Guidelines?	Tier Three
What are you using as the endpoint for a phenobarbitol/thiopentone coma for Traumatic Brain Injury?	Burst Suppression
What do you need to avoid when using a phenobarbitol/thiopentone coma in Traumatic Brain Injury?	Hypotension
What counts as mild hypothermia in tier three of the SIBICC Guidelines?	35-36
A secondary decompressive craniectomy occurs in what tier of the SIBICC Guidelines?	Tier Three

You're getting worse if

GCS Motor Score Drops by 1 or more
Pupils react less
Pupils become asymettrical
Bilateral mydriasis (dilated pupils)
Focal motor defecit
Herniation Syndrome/Cushings Triad
Bradycardia
Irregular Respirations
Widened Pulse Pressure ²

Flashcard	type:basic
In Traumatic Brain Injury, the four signs you are getting worse are:	GCS Motor Decreases By One Pupils Change (Less Reactive, Asymettrical, Dilated) Focal Motor Weakness Cushings Triad
The Three Parts of Cushings Triad Are	Bradycardia Irregular Respirations Widened Pulse Pressure

If someone is getting worse you should

Evaluate them immediately
Treat empirically if concern of herniation
Hyperventilation
Bolus hypertonic saline
Do they need a scan? (They probably do)
Do they need an operation? ²

If someone's getting worse it might be

CNS
Expanding mass lesion
Cerebral oedema
Increased ICP
Stroke
Seizures
Critical Illness
Hypotension
Hypoxia
Infection
Systemic
Electrolyte/Metaboilic
Dehydration
Hyper/hypothermia
Comorbidity
Drugs
- Medications
- Withdrawal ²

When should you stop checking ICP

Acceptable ICP for 72hrs, most would take out regardless of motor GCS
Acceptable ICP for 48hrs, but motor GCS poor, many would leave it in

Flashcard	type:basic
When should you stop checking ICP in Traumatic Brain Injury?	After it's been OK for around 48-72 hours

When should you stop sedation?

I don't get this recommendation.

It tells you what to do based on what their motor score is. But how do you know what their motor score is if they're still on sedation?