TBI

Question 1

Causes of TBI

Answer 1

Blunt impact
Penetrating injury
Blast Wave
Accelerating-Decelerating Force

Question 2

Secondary Damages

Answer 2

Neuronal health and tissue loss
BBB breakdown and edema
Upregulation of inflammatory mediators
Gliosis and cell infiltration

These are more likely to occur if patient is not taken to the hospital ASAP

Question 3

Primary Brain Injury

Answer 3

Initial biochemical process that occur at the impact of injury

Question 4

Secondary Brain Injury

Answer 4

Delayed brain insult that occurs in minutes, hours, days after primary injury

Question 5

TBI goals

Answer 5

Stabilize and Attenuate secondary injury

Restore nerve or neuronal injury

To treat hypotension and hypoxia

Question 6

When is GCS performed?

Answer 6

Within 48 hours of injury

Question 7

CGS Scores

Answer 7

Higher Scores= better
Severe 3-8
Moderate 4-12
Mild 13-14
Normal 15

Question 8

Physical Exam

Imaging

Labs

Neuro signs and symptoms

Answer 8

Skull fractures, lacerations, CSF, otorrhea or rhinorrea

CT head scan

Arterial blood gas, urine drug screening, Blood alcohol concentration, electrolytes

Seizures, paresthesia, moderate to severe headaches, dizziness, post traumatic amnesia

Question 9

Therapeutic goals

Answer 9

Optimize Cerebral Perfusion Pressure (CPP)

Treat increased ICP

Question 10

CPP Formula

Answer 10

CPP= Mean Arterial Pressure (MAP)- Intracranial Pressure (ICP)

Question 11

MAP Formula

Answer 11

[SBP + (2 x DBP)]/3

Question 12

ICP should be less than?

CPP should range

Answer 12

20 mmHg

50-70mmHg

Question 13

For hypotension and CPP <50 mmHg tx with?

Answer 13

IV fluids and possible vasopressors

Question 13

For hypotension and CPP <50 mmHg tx with?

Answer 13

IV fluids and possible vasopressors

Question 14

CPP goals should not exceed ______ with fluids or vasopressors

Answer 14

70 mmhg

Question 15

Patients not receiving vasopressors with CPP> 70mmhg after resuscitation do not require ______

Answer 15

HTN meds to lower CPP target range, unless BP is dangerously high or causing sequelae

Question 16

Patients not receiving vasopressors with CPP> 70mmhg after resuscitation do not require ______

Answer 16

HTN meds to lower CPP target range, unless BP is dangerously high or causing sequelae

Question 17

Post resuscitation fluid goal is

Answer 17

euvolemia

Question 18

Hemodynamic Management tx

Answer 18

Isotonic fluids are used. Normal saline is preferred since balanced solutions are relatively hypotonic and may worsen cerebral edema

Question 19

BP guidelines for hemodynamic management

Answer 19

SBP >/=100 mmHg in pts 50-69

SBP >/=110 mmHg in pts 15-49 or >70 yo

Question 20

Increase in MAP may lead to

Answer 20

Elevated ICP due to increased cerebral blood volume and hyperaemia

Question 21

Decrease in MAP may be associated with

Answer 21

hypoperfusion and ischemia

Question 22

Hemodynamic management goal

Answer 22

Optimisation of CBF

Question 23

1st line for post traumatic seizures for first 7 days following injury

Answer 23

Phenytoin, but some prefer levetiracetam

Question 24

Venous thromboembolism prophylaxis tx

Answer 24

Chemoprophylaxis w/ either unfractionated heparin 5000 units tid or enoxaparin 40 mg/day 24 hours following admission in TBI pts with stability comfirmed on repeat imaging

Question 25

Coagulopathy may result from existing patient medications such as

Answer 25

warfarin and antiplatelet agents

Question 26

How can pts taking warfarin be managed?

Answer 26

Prothrombin complex concentrate (PCC) and Vit K

Question 27

Glucose management tx

Answer 27

Hyper and hypoglycaemia are associated with worsened neurologic conditions Target: 140-180 mg/dl

Question 28

When is intensive insulin therapy not recommended?

Answer 28

To target a glucose level b/w 80-110 mg/dl because outcomes are not great

Question 29

Temperature management tx

Answer 29

Fever should be avoided Normothermia should be attempted with the use of antipyretic medications surface-cooling devices, or end-vascular temperature management catheters

Question 30

How does fever worsen ICP?

Answer 30

It increases metabolic demand, blood flow and blood volume

Question 31

What best describes the most appropriate use of therapeutic hyperventilation for ICP control in the management of TBI patients?

Answer 31

Used briefly to a PCO2 goal of 30 to 35 mm Hg (4.0-4.7 kPa) but only beyond the first 24 hours after a TBI

Question 32

Hypotension is associated w/ propofol and what should be used to help maintain CPP goals ?

Answer 32

Fluids and vasopressors

Question 33

What is generally the sedative of choice for controlling ICP in TBI patients?

Answer 33

Propofol

Question 34

Pharmacotherapy- Intracranial HTN targeting ICP 1st line

Answer 34

IV sedation and analgesia Empiric use of opioids + sedatives for pain control Sedative of choice (propofol) , rapid onset short duration Midazolam may be used in place of propofol (but greater ADRs) , preferred Benzoic due to short half life and easier titration

Question 35

Pharmacotherapy Hyperosmolar agents, used to mobilise water from brain to vasculature and from cranial space via osmotic gradient

Answer 35

1st line: mannitol 3% and hypertonic saline (3%-23.4% NaCl) Dose: 0.25g/kg IV over 30 minutes may repeat 6-8 hrs AE: diuresis, AKI, rebound increase in ICP Do not administer if serum osmolarity>320 mOsm/L Hypertonic Saline helps w/ hypovolemic pts. Do not use is serum Na exceeds 155 mEq/L

Question 36

2nd line for ICP control (used in pts CI to 1st line or refractory to 1st line)

Answer 36

Barbiturates Phenobarbital initial loading dose 25mg/kg infused IV over 4 hours Tapered off during 24-72 hrs after adequate ICP control achieved and maintained from 24-48 hrs

Question 37

Other Miscellaneous Pharmacotherapy

Answer 37

Loop diuretics - Potential 2nd line for fluid overload pts, not to be used in hypovolemic TBI pts Neuromuscular blocking agents- used for additional ICP control where sedation control dose is maximised due to hypotension or propofol limitations for example, Conivaptan (arginine vasopressin antagonist) shown to decrease ICP Hypotension- treated with IV fluids and crystalloids such as hypertonic saline , Ringers Lactate, Dextrose 5% vasopressors nicardipine-in persons with HTN

Question 38

Non Pharm

Answer 38

Head positioning - raise head of bed -decreases ICP and increases CPP Hyperventilation -decreases ICP CSF drainage - 1st line in pts with ventriculostomy

Question 39

Seizure risk factors

Answer 39

CGS less than 10 Intracelebral hematoma Depressed skull fracture

Question 40

Phenytoin serum levels

Answer 40

10-20 mcg/ml

Question 41

VTE prophylaxis

Answer 41

CT scan to rule out intracranial bleeding Consider anticoagulation risk of intracranial bleeding Pnuematic compression devices can be used until drug therapy can be used Recommended drug therapiES- LMWH OR LOW DOSE UNFRACTIONATED heparin Enoxaparin superior to low dose unfractionated heparin