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CI2 > Management of Traumatic Brain Injury in ICU > Flashcards

Management of Traumatic Brain Injury in ICU Flashcards

1
Q

What is acquired brain injury (ABI)?

A

Any brain damage that occurs after birth

  • Accident or trauma (TBI)
  • Stroke
  • Brain infection
  • Alcohol/drugs
  • Disease processes (e.g. Parkinson’s)
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2
Q

What is traumatic brain injury (TBI)?

A
  • Subset of ABI
  • Involves injury to brain causes by external force (e.g. blow to the head)
  • Causes rapid movement of the brain inside the skill
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3
Q

What are the primary causes of TBI in Australia?

A
  • Falls
  • Transportation
  • Assault
  • Sport (e.g. football)
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4
Q

What are the 5 different times of head injury?

A
  • Intracerebral hematoma/contusion
  • Subarachnoid haemorrhage
  • Subdural haemorrhage
  • Epidural haemorrhage
  • Difffuse axonal injury
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5
Q

What are the characteristics of intracerebral hematoma/contusion?

A
  • Location: Brain
  • CT findings: Multiple microhaemorrhages
  • Injury: Microhaemorrhages
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6
Q

What are the characteristics of subarachnoid haemorrhage?

A
  • Location: Subarachnoid space
  • CT findings: Blood in sulci & fissures
  • Injury: Tear of subarachnoid vessels
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7
Q

What are the characteristics of subdural haemorrhage?

A
  • Location: Subdural space
  • CT findings: Crescent (sickle shaped)
  • Injury: Tear of bridging veins
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8
Q

What are the characteristics of epidural haemorrhage?

A
  • Location: Epidural space
  • CT findings: Biconvex (football shaped)
  • Injury: Tear of meningeal arteries
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9
Q

What are the characteristics of diffuse axonal injury?

A
  • Location: Brain
  • CT findings: No abnormalities
  • Injury: Shearing of white matter tracts
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10
Q

What happens without adequate cerebral perfusion?

A

Brain cells die (secondary brain injury)

Brain death = death

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11
Q

How is cerebral perfusion pressure (CPP) calculated?

A 
CPP = MAP - ICP
Normal = <70mmHg
Critical = <55mmHg
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12
Q

What are the strategies for managing TBI?

A
  • Reduce ICP
  • Improve CPP
  • Maximise brain tissue oxygenation (mechanical ventilation, maintain respiratory function)
  • Reduce brain’s metabolic demand
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13
Q

How can ICP be reduced?

A
  • Posture (bed tilt)
  • Mechanical ventilation
  • Drainage of CSF (EVD)
  • Sedation, paralysis & analgesis
  • Hypertonic saline, mannitol
  • Barbiturate coma
  • Craniectomy (cutting out piece of skull)
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14
Q

How can CPP be improved?

A
  • Fluid management

- Vasopressor support

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15
Q

How can the brain’s metabolic demands be reduced?

A
  • Sedation +/- paralysis (medically induced coma)

- Cooling (limited evidence)

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16
Q

What evidence is there for bi-frontal decompressive craniectomy in TBI?

A
  • Multicentre RCT
  • Lower ICPs in ICU
  • Fewer interventions for ICP
  • Fewer days in ICU
  • But worse outcomes at 6 months
17
Q

What evidence is there for prophylactic chest physio for ventilated patients with a TBI?

A

Pateman et al 2009

  • Prospective RCT of ABI patients with GCS <9
  • Treatments every 24 hours vs no chest physio
  • 33 developed VAP
  • No differences between groups
18
Q

What is the connection between hyperinflation & ICPs?

A
  • Hyperinflation blows off CO2 (hyperventilation)
  • In blood vessels, CO2 acts as a vasodilator
  • Low CO2 levels = relative vasoconstriction
  • Vasoconstriction in the brain = lower ICP
19
Q

What are some tips for suction with unstable ICPs?

A
  • Minimise number of passes (1 long better than 10 short passes)
  • Ensure pre-oxygenation to avoid hypoxia
  • Cluster care to minimise spikes in ICP
20
Q

How can contracture be prevented in TBI?

A
  • Maintain oppositional ROM in hands (rolled up towels in hands, resting splints)
  • Maintain calf length (resting splints at plantar grade, serial casting)
  • Maintain shoulder ROM as able (hand behind head position, abduction on table pillows if SOOB)
21
Q

What evidence is there for passive ROM exercise to prevent contracture?

A

Cochrane review Dec 2013

  • No evidence that PROM exercises prevent contracture
  • Previous evidence suggests prolonged stretch for changes in muscle length
22
Q

What evidence is there for the use of tilt tables in ICU?

A

Chang et al 2004

  • Survey of physios in Australian public ICUs
  • 67% use tilt tables to facilitate early rehab
23
Q

What did Paulus et al 2012 find regarding MHI in ICU?

A
  • Systematic review of adults intubated & mechanically ventilated
  • Failed to show benefits of MHI in intubated & mechanically ventilated patients
  • Associated with short-term side-effects
24
Q

What did Berney et al 2002 find regarding positioning & MHI in ICU?

A
  • Prospective, randomised, crossover study
  • Patients intubated & ventilated
  • Addition of head down tilt to physio (including MHI) increases sputum production & improves PEF
25
Q

What did Berney et al 2004 find when comparing MHI & VHI?

A
  • Randomised double crossover study
  • Patients intubated & ventilated
  • MHI followed by VHI 2 hours later, then reverse the next day
  • Both methods improve static pulmonary compliance & clear similar volumes of secretions

CI2 (17 decks)

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