Traumatic Brain Injury EXAM 2 Flashcards
What is the GCS score of a severe traumatic brain injury?
between 3-8
9-12 = moderate
What are the two types of primary brain injury?
-Blunt force head trauma (car accident, the brain may bounce back will be damaged on both sides)
-Penetrating head trauma (gunshot)
What is the main issue that results from a brain injury? (Secondary Injury)
Ischemia of brain tissue
others:
-increased intracranial pressure (from brain injury or bleeding)
-Vasospasms -> lead to decreased perfusion (may be induced by blood that irritates the vessels)
-Seizures
-Metabolic derangements (sodium/water regulation)
-increased metabolism and coagulation
What are the immediate goals after a brain injury?
-make sure the airway is free, manage BP
-Goal SBP > 90 mmHg (to ensure perfusion of the brain)
-use to 0.9% NS or LR to ensure goal BP (may use colloids or hypertonic saline, Albumin showed increase in mortality)
-use Vasopressor if still hypotensive after giving fluids
What is the goal ICP (intracranial pressure?
What is the Cerebral Perfusion Pressure (CPP)?
What is the goal CPP?
-goal ICP <20 mmHg
-CPP = MAP - ICP
goal CPP: 50-70 mmHg
-increase MAP with vasopressors and fluids (MAP should be high to overcome the ICP (SBP >90)
-decrease ICP
What is the consequence if the ICP is too high?
Brain stem herniation = sudden death
How do sedation and analgesics help in brain injuries?
reduce ICP
pain can cause agitation in the patients, which can increase ICP
What is the advantage and disadvantage of Fentanyl in patients with brain injuries?
Which other pain meds can be used?
advantage: fast on and fast offset
disadvantage: it may increase ICP
-may use morphine or oxycodone
What is the sedative of choice for patients with brain injury?
Propofol
-fast on, fast offset
-neuroprotective abilites
What advantages do Benzos provide as a sedative in patients with brain injury?
-anxiolytic
-antiseizure properties
Barbiturates (Phenobarbital) as the last line for sedation
Which drugs are used to reduce ICP?
Osmotic agent:
Mannitol (0.25 - 1g/kg IV q4h)
-moves fluid out of the brain (by using osmotic pressure)
Hypertonis saline (3-24%)
What are the side effects associated with Mannitol?
-AKI (avoid in renal failure)
-hyperkalemia
-CHF exacerbation
-pulmonary edema
monitor:
sodium (keep <160 mEq/L)
serum osmolality (keep <320 mEq/L)
fluid losses
must keep Mannitol in a warmer to prevent crystallization
What is a significant side effect of Phenobarbital when used to induce a Barbiturate coma?
What helps to reduce the side effect?
Hypotension
-slow infusion rate if it occurs
Barbiturate coma is the last line
What is the steady state concentration and ICP goal when inducing Barbiturate coma?
30-40 mcg/ml
-once ICP is at goal run it for 24-48h -> then taper over 24-72h
the goal is to stop EEG burst suppression to give the brain time to heal
What are the side effects of Barbiturates used for a Barbiturate coma?
-hypotension
-decreased GI tone
-respiratory depression (need a ventilator)
-DDI due to CYP3A4 induction
Which drug should be avoided for lowering ICP due to increased mortality?
Corticosteroids
ADE:
-GI bleeding
-glucose intolerance
-electrolyte abnormalities
- infection
Which drugs are used to manage seizures in patients with brain injury?
-Benzos
-Levetiracetam (Keppra)
-Phenytoin
-Fosphenytoin
What are the risk factors that put patients at a higher risk for a seizure?
-GCS < 10
-Cortical contusion
-Depressed skull fracture
-Hematoma (subdural, epidural, or intracerebral)
-Penetrating head trauma
-Seizure within the first 24 hrs after injury
How are patients with high risk for seizures treated?
prophylactic antiseizure meds for 7 days
-Phenytoin
-Fosphenytoin
-Keppra (can cause agitation)
What is the treatment for Vasospams in patients with traumatic brain injury?
Triple H therapy
-Hypervolemia (IV fluids)
-Hypertension (provide perfusion to the area)
-Hemodilution (dilute the blood)
Which drug may used for Vasopasms?
Nimodipine (Nimotop)
-60 mg PO/PT q4h for 21 days
Which hormone is affected in Diabetes insipidus?
How does it affect urine output?
-a brain injury can cause depletion or resistance to ADH
-diuresis of free water (urination)
-elevated sodium levels (hypovolemia)
What is the treatment for Diabetes insipidus for patients with a traumatic brain injury?
-Resuscitate with lots of NS
-DDAVP (desmopressin) - synthetic ADH
How is ADH affected in SIADH?
What happens to sodium levels and urine output?
too much ADH
-the body keeps free water in the body
-diluted Na -> hyponatremia
-concentrated urine
What is the treatment for SIADH for patients with a traumatic brain injury?
fluid restriction
-loop diuretics
-hypertonic saline (replenish sodium) -> if at risk for hypernatremic seizure
-Demeclocycline (for chronic management, onset 1 wk)
-Vaptans (aquaretics)
Which drugs can cause SIADH?
-antiseizure meds
-Antipsychotics
-Antidepressants (SSRIs)
Which drugs are considered for supportive care in patients with brain injury?
-max dose DVT prophylaxis (not if they have an active brain bleed): Enoxaparin 30 mg SC q12h
-need early nutrition (due to stress hyperglycemia), high amounts of protein (catabolic and high metabolic state)
-Stress ulcer prophylaxis
-may need more frequent drug dosing (high drug metabolizing)
-Nicardipine if they are hypertensive
-hyperthermia treatment (thermoregulation is impaired and may cause high temperature): Tylenol, NSAIDs, cooling blankets
