Meds: TBI & Spinal Injury Flashcards
Vasopressors used in neurogenic shock
- Phenylephedrine Hydrochloride
- Dopamine
- Norepinephrine
There is insufficient evidence to support the use of _______ in spinal cord injury
Steroids
Hypovolemia in TBI patient is dangerous. What fluids would you use?
AVOID HYPOTONIC SOLUTIONS & solutions with sugar, rather use HypERtonic solutions -> Lactated Ringers & Normal Saline 3%-23.4%
Monitor sodium levels. Hyponatremia can cause brain swelling
Careful not to fluid overload and cause pulmonary edema
Treat a patient with the elevated ICP Hypotension.
Hypertonic saline : normal saline 3-23.4%
Not a diuretic
Treatment of patient with elevated ICP who is normotensive and euvolemic
Mannitol (Osmitrol)
20% solution (20g in 100ml of solution)
Mannitol (Osmitrol) is contraindicated in what patients? Why?
TBI patient who are Hypotensive &/or Hypovolemic. Because it is a potent osmotic diuretic and can worsen hypotension and cerebral ischemia
Treatment for a euvolemic patient w/ TBI in observation who develops an acute onset of a dilated pupil, has hemiparesis, or loses consciousness? How is it given
Mannitol (Osmitrol)
In this case, give a bolus 1g/kg rapidly over 5 minutes & immediately transfer to CT scanner or operating room if a causative surgical lesion is already identified
Mannitol dosing to control elevated ICP? What should be avoided?
0.25-1g/kg; arterial hypotension (systolic BP < 90 mmHg) should be avoided
When using Manitol for treatment of elevated ICP. What should be used for monitoring? What is a contraindication? Goals of treatment?
ICP Monitor, unless evidence of herniation. Keep Sasm < 320mOsm. maintain euvolemia, and use bolus rather than continuous drip
Sasm (serum osmolality)
What is used to control elevated ICP refractory to maximum standard medical & surgical treatment? What is essential before and during this treatment?
High dose barbituates
Hemodynamic stability
Barbituats should not be used in patients with ____ & ____
Hypovolemia & Hypotension
*can worsen hypotension so they should not be used in the acute resusitve phase
The long ____ of most barbiturates prolongs the time for determining ___, which is a consideration in patients with devestating & likely nonsurvivable injury
Long 1/2 life which will prolong the time for determining brain death
Early use of this class of medications can control acute seizures, however early use does NOT change long-term traumatic seizure outcome
Anticonvulsants
3 main factors linked to high incidence of late elilepsy
- Seizure occurring within the 1st week
- Intracranial hematoma
- Depressed skull fracture
______ can inhibit brain recovery, so they should be used only when absolutely necessary
Anticonvulsants
2 anticonvulsants generally used in the acute phase
Phenytoin (Dilantin) & Fosphenytoin (Cerebyx)
Adult dosing of Phenytoin
1g of Phenytoin IV NO faster than 50 mg/min —> maintainance dose is 100mg/8hrs with dose titrated to achieve therapeutic serum levels
Used in addition to phenytoin until seizure stops
Valium (Diazepam) or Ativan (Lorazepam)
Control of continuous seizures may require
General anesthesia
Prophylactic use of _____ & _____ is not recommended for preventing late posttraimatic seizures (PTT).
Phenytoin (Dilantin) or Valproate (Depakote)
____ is recommended to decrease the incidence of early PTS (within 7 days of injury), when overall benifit outweigh the complications associated with such treatment.
Phenytoin
However, early PTS ___has? or has not?__ been assoc w/ worse outcomes.
Has NOT
May be given for sedation in patient with suspected TBI? Reversal agent?
Midazolam (Versed)
Reverse with Flumazenil
May be given for analgesia in patient with suspected TBI? Reversal agent?
Low dose IV narcotic
Reverse with naloxone
Although ____ is recommended for the control of ICP, it is not recommended for improvement in mortality or 6m outcome. It can produce significant morbidity when used in high dose.
Diprovan (Propofol)
Reversal for antiplatelent (aspirin, plavix)
Platelets
May need to repeat: consider desmopressin acetate (Deamino-Delta-D-Arginine Vasopressin)
Reversal ageants for coumadin
FFP
VitK
Protrombin complex concentrate (Kcentra)
Factor 7A
Reversal agent for Heparin
Protamine sulfate
Monitor PTT
Reversal for low molecular weight heparin (Lovenox (enoxaparin)
Protamine sulfate
Reversal agent for Direct Thrombin Imhibotors: dabigatran etexilate (Pradaxa)
Idarucizumab (Praxbind)
May benefit from prothrombin compex concentrate (Kcentra)
Reversal agent for Xarelto (rivaroxaban)
N/A
May benefit from prothrombin compex concentrate (Kcentra)
