Alyssa Morris, R4 August 12, 2010 Thanks to Dr Adam Oster HEAD TRAUMA
OBJECTIVES • Prehospital intubation of a head injury • Anti-seizure prophylaxis • Intubation of a head injury • Premedication • Induction agent • Management of herniation • Mannitol • Hypertonic saline • Cooling in TBI • CT head rules
CASE • 27M restrained driver in a single vehicle MVA at highway speed. • GCS 13, no obvious head trauma, other vitals stable, combative • 26F restrained passenger in the rollover GCS 8, obvious lacerations and bleeding from scalp, BP 102/60, P= 110, 02 sats 94% RA
Objective: determine if ALS care in field for trauma patients improves morbidity and mortality • Design: Before-after clinical trial • Population: n= 2867, trauma pts >16y.o, severity score>12 • Results: (ALS v. BLS) • Overall Survival 81.1% v. 81.8% (p=0.65) • Survival in GCS<9 50.9% v. 60.0% (p=0.02)
CASE CONT… • The patients are now in the ED. • 27M GCS 14 one hour after exam, no obvious amnesia, slightly agitated, vitals stable and nothing else on exam. • 26F GCS 8 obvious depressed skull fracture.
QUESTIONS • Do you want to ask radiology for a CT head for these patients? • What were the outcomes the rule was predicting? • What are the High Risk criteria? • What are the Medium Risk criteria?
Objective: develop a highly sensitive clinical decision rule for use of CT in pts w minor head injury • Inclusion Criteria: • blunt trauma to the head w witnessed LOC • definite amnesia • witnessed deterioration • initial ED GCS >=13 • injury w/i past 24h
Exclusion Criteria • <16y.o • Minimal head injury • No clear hx of trauma • Penetrating skull injury • Focal neuro deficit • Unstable vital signs • Had a seizure before ED assessment • Bleeding disorder or anticoagulated • pregnant
High Risk (for neurological intervention) • GCS < 15 at 2 hrs after injury • Suspected open or depressed skull # • Any sign of basal skull fracture • Vomiting >= 2 episodes • Age >= 65 • Medium Risk (for brain injury on CT) • Amnesia before impact >= 30 min • Dangerous mechanism • Pedestrian • Ejected • Fall from elevation >=3ft or 5 stairs
CASE CONT… The nurse asks if you want to give these patients dilantin to prevent a seizure given they have head injuries. The female reportedly has already had a seizure but the male has not. Q: Will you give dilantin to the 27M? Q: Will you give dilating to the 26F?
6 randomized controlled trials included • Results • For every 100 pts treated with AEDs, 10 would be kept seizure free in 1st week • No reduction in mortality • No reduction in neurological disability • No reduction in late seizure onset • Conclusion • Does reduce early PTS but no outcome benefit • No evidence to support routine use at any time after injury
Practice Recommendations • Prophylactic treatment with phenytoin, beginning with an IV loading dose, ASAP after injury should be used routinely to prevent early PTS • Prophylactic treatment should not be used beyond first 7 days after injury
Recommendations • LEVEL I • Insufficient data • LEVEL II • AEDs are indicated to decrease the incidence of early PTS (w/i 7d of injury). However, early PTS is not associated with worse outcomes. • Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS
Recommendations • Standards • Insufficient data • Guidelines • Prophylactic use of AEDs to prevent late PTS is not recommended • Options • Prophylactic use of AEDs to prevent early PTS may be considered as a treatment
CASE CONT… • 27M is becoming more combative and you are preparing to intubate him. Q: Will you premedicate? Q: What will you use for induction?
LIDOCAINE • 1.5mg/kg 3 minutes before RSI • No article answering our exact question • Found 6 papers • Benefit shown in: • Brain neoplasms undergoing resection • ETT suctioning (already intubated and Mx) • No benefit or harm shown in: • Prolonged decreased MAP (CPP= MAP-ICP) • Has to be given minutes before RSI
Objective: use swine model with ICP monitors in to monitor changes with different versions of RSI • Groups: 1)Thiopental 2) Thiopental and Sux 3) Lido, Thiopental, Sux 4) pancuronium, lido, thiopental, sux
FENTANYL • Advocated for use in premedication • Rosen’s • AIME • US airway course • 3mcg/kg 3 minutes before • No evidence from our setting or at time of ETI
Objective: determine the effect of fentanyl on ICP in head injured sedated patients with monitors in place • Design: randomized • Results: • Significant increase in ICP transiently • Significant decrease in MAP • Significant decrease in CPP
Objective: determine the effect of fentanyl on ICP and CBF in sedated patients with severe head injury • Design: Randomized • Results: • Significantly increased ICP • Significantly decreased MAP • No change in CBF
KETAMINE • The case against Ketamine • Gardner et al. Intracranial CSF pressure in man during ketamine. AnesthAnalg. 1972;51:741-5. • Shapiro et al. Ketamine anesthesia in patients with intracranial pathology. Br J Anesth. 1972;44:1200-04. • Takeshita et al. The effects of ketamine on cerebral circulation and metabolism in man. Anesthesiology. 1972;36:69-75.
Objective: determine effect of IV Ketamine on ICP/CPP/MAP • Population: 8 ventilated patients with ICP monitors in place • Intervention:1.5, 3 and 5mg/kg IV • Results: • Significant reduction in ICP
Design: prospective double-blind RCT • Population: 25 pts with severe head injury • Intervention: continuous infusion of ketamine-midazolamv. sufentanil-midazolam • Results • No significant difference in daily ICP • No significant change in daily CPP
Design: prospective RCT • Population: 35 patients with moderate or severe head injury • Intervention: ketamine-midazolamv. fentanyl-midazolam infusions • Results • Slightly higher ICP in ketamine group (2mmHg) • Slightly higher CPP in ketamine group (8mmHg)
KETAMINE THEORIES • Increases ICP • Old studies in patients with abnormal CSF flow • Increases CPP • Not sure of the effect this has on regional blood flow to penumbra and outcome assoc w this • Neuroprotective • NMDA R antagonist decreases glutamate (neurotoxic) ?neuroprotective • Some animal models, nothing strong in humans
CASE CONT… • Your patients are now both intubated. • What are you initial vent settings and what goal(s) do you give the RT? • If the patient shows evidence of herniation how does this change you approach to ventilation?
VENTILATION HEAD INJURY • Not Herniating • Mode: AC • Vt= 8cc/kg • PEEP= 5 • PCO2= 35-40 • RR= 10-18 • Herniating • Hyperventilate until clinical recovery or definitive Mx
LEVEL I • Insufficient evidence • LEVEL II • Prophylactic hyperventilation (PaCO2 of 25) isnot recommended • LEVEL III • Hyperventilation is recommended as a temporizing measure for the reduction in elevated ICP
STANDARDS • Insufficient data • GUIDELINES • Insufficient data • OPTIONS • Mild hyperventilation (PCO2<35) should be avoided • Mild hyperventilation may be considered for long periods of refractory high ICP • Aggressive hyperventilation (PCO2<30) may be considered for brief periods in cases of cerebral herniation or acute neuro deterioration
CASE CONTINUED • The female patient now has a blown pupil. • How do you want to manage this?
HERNIATION MX • HYPEROSMOLAR THERAPY • Mannitol • Hypertonic Saline • Barbiturates • HYPERVENTILATION • SURGERY
Objective: Compare high dose barbiturates to mannitol for ICP control • Design: RCT • Results: • ICP significantly lowered in mannitol group • CPP significantly improved • Mortality improved
MANNITOL • Level I Evidence • Insufficient data to support level I evidence • Level II Evidence • Mannitol is effective for control of ICP • Dose of 0.25g/kg-1g/kg • Avoid SBP<90 • Level III Evidence • Restrict to use in patients with signs of herniation OR w an ICP monitor in
Design: Prospective • Objective: effect 3% Saline continuous infusion on refractory elevated ICP in severe HI pediatric patients • Results • Statistically significant decrease in ICP • Statistically significant decrease in # of ICP spikes • Statistically significant increase in CPP
Design: prospective RCT pilot • Population: 9 patients with ICP>20 • Intervention: 200cc bolus of 20% Mannitolv 100cc bolus of 7.5% Saline over 5 minutes • Results: • Significant reduction in ICP with HS compared to mannitol • Both reduced ICP (13mmHg v 7.5mmHg)
HYPERTONIC SALINE • Current evidence is not strong enough to make recommendations on the use, strength and method of administration of hypertonic saline
Standards • Not enough evidence • Guidelines • Not enough evidence • Options • HS is effective for control of ICP after severe head injury • 3% Saline 0.1mL/kg to 1.0mL/kg continuous • Mannitol is effective for control of ICP after severe head injury • 0.25-1.0g/kg bolus
CASE CONT… • Your patients are now intubated, stable and ICU is rounding so want you to manage them for a few hours. • The nurse asks if you want to cool the patients. • Are you going to cool this patient?
Design: large multicenter RCT • Intervention: hypothermia (33C) initiated w/i 6 hrs for 48hrs v. normothermia • Population: n= 362, age 16-65 with coma after CHI • Results: (hypo v. normo) • Poor functional outcome: 57% vs 57% • Mortality: 28% vs 27% • Fewer hypothermic patients had high ICP
Design: multicenter, international, RCT • Intervention: hypothermia (32.5C for 24hr w/i 8hrs of injury) v. normothermia (37C) • Population: n= 225, Age 1-17 with TBI and GCS<8, CT w brain injury and need for mechanical ventilation • Results: (hypo v. normo) • Unfavorable outcome 31% v 22% P= 0.14 • Deaths 23 v 14 P=0.06
LEVEL I EVIDENCE • Insufficient data • LEVEL II EVIDENCE • Insufficient data • LEVEL III EVIDENCE • Pooled data indicate hypothermia is not significantly associated with decreased mortality • It is associated with significantly higher outcome scores • Need to maintain for >48hrs
STANDARDS • Insufficient data • GUIDELINES • Insufficient data • OPTIONS • Extrapolated from adult data, hyperthermia should be avoided • Despite lack of evidence, hypothermia may be considered in cases of refractory intracranial htn
TEMP CONTROL • Maintain normothermia • What if they are febrile?
CASE IN REVIEW • Intubate in field? • CT head rules pocket guide • AED prophylaxis? • Premedication with lido/fentanyl? • Induction with ketamine? In whom? • Use of mannitol for herniation? • Use of hypertonic saline for herniation? • Vent strategies? • Cooling?
CASE 2 • 5M who fell off a chair and hit the temporal side of his head on the side of a table. No loss of consciousness. Next day vomits 6 times and complains of headache • 7F falls from the Jungle Gym (7ft) and hits her head. No amnesia, no LOC, normal exam • 18m.o. M fell from change table onto hardwood floor. Cried immediately. Has had a good feed but is slightly irritable when you examine him