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Pharmacotherapy 3 > TBI > Flashcards

TBI Flashcards

1
Q

Causes of TBI

A

Blunt impact
Penetrating injury
Blast Wave
Accelerating-Decelerating Force

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2
Q

Secondary Damages

A

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

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3
Q

Primary Brain Injury

A

Initial biochemical process that occur at the impact of injury

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4
Q

Secondary Brain Injury

A

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

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5
Q

TBI goals

A

Stabilize and Attenuate secondary injury

Restore nerve or neuronal injury

To treat hypotension and hypoxia

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6
Q

When is GCS performed?

A

Within 48 hours of injury

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7
Q

CGS Scores

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

Physical Exam

Imaging

Labs

Neuro signs and symptoms

A

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

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9
Q

Therapeutic goals

A

Optimize Cerebral Perfusion Pressure (CPP)

Treat increased ICP

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10
Q

CPP Formula

A

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

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11
Q

MAP Formula

A

[SBP + (2 x DBP)]/3

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12
Q

ICP should be less than?

CPP should range

A

20 mmHg

50-70mmHg

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13
Q

For hypotension and CPP <50 mmHg tx with?

A

IV fluids and possible vasopressors

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13
Q

For hypotension and CPP <50 mmHg tx with?

A

IV fluids and possible vasopressors

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14
Q

CPP goals should not exceed ______ with fluids or vasopressors

A

70 mmhg

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15
Q

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

A

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

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16
Q

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

A

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

17
Q

Post resuscitation fluid goal is

A

euvolemia

18
Q

Hemodynamic Management tx

A

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

19
Q

BP guidelines for hemodynamic management

A

SBP >/=100 mmHg in pts 50-69

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

20
Q

Increase in MAP may lead to

A

Elevated ICP due to increased cerebral blood volume and hyperaemia

21
Q

Decrease in MAP may be associated with

A

hypoperfusion and ischemia

22
Q

Hemodynamic management goal

A

Optimisation of CBF

23
Q

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

A

Phenytoin, but some prefer levetiracetam

24
Q

Venous thromboembolism prophylaxis tx

A

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

25
Q

Coagulopathy may result from existing patient medications such as

A

warfarin and antiplatelet agents

26
Q

How can pts taking warfarin be managed?

A

Prothrombin complex concentrate (PCC) and Vit K

27
Q

Glucose management tx

A

Hyper and hypoglycaemia are associated with worsened neurologic conditions

Target: 140-180 mg/dl

28
Q

When is intensive insulin therapy not recommended?

A

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

29
Q

Temperature management tx

A

Fever should be avoided

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

30
Q

How does fever worsen ICP?

A

It increases metabolic demand, blood flow and blood volume

31
Q

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

A

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

32
Q

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

A

Fluids and vasopressors

33
Q

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

A

Propofol

34
Q

Pharmacotherapy- Intracranial HTN targeting ICP 1st line

A

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

35
Q

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

A

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

36
Q

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

A

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

37
Q

Other Miscellaneous Pharmacotherapy

A

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

38
Q

Non Pharm

A

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

39
Q

Seizure risk factors

A

CGS less than 10
Intracelebral hematoma
Depressed skull fracture

40
Q

Phenytoin serum levels

A

10-20 mcg/ml

41
Q

VTE prophylaxis

A

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

Pharmacotherapy 3 (5 decks)

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