Treatment of TBI

Question 1

First focus for TBI treatment

Answer 1

Extracranial stabilisation
- Correction of tissue perfusion deficits, typically as a result of hypovolaemia
- Optimising systemic oxygenation and ventilation

Question 2

Goals for intracranial stabilisation after TBI

Answer 2

Optimising cerebral perfusion
Decreasing ICP
Minimising increases in cerebral metabolic rate

Question 3

Is fluid restriction useful in TBI

Answer 3

no- it is contraindicated
It does not reduce or prevent cerebral oedema

Question 4

Shock rates to give after TBI

Answer 4

¼ aliquots of ‘shock’ rates
15-20ml/kg boluses of Hartmann’s
2.5-5ml/kg Colloids

Question 5

Benefits of hypertonic saline after TBI

Answer 5

Rapidly restores circulating volume
draws fluid from interstitium to reduce oedema

Question 6

When to give oxygen supplementation after TBI

Answer 6

You want : SpO2 >95% or PaO2 >90mmHg
If:
<89% likely severe hypoxaemia with marked consequences
<75% life-threatening hypoxaemia

Question 7

Consequence of high PaCO2 after TBI

Answer 7

Worsening of ICP

Question 8

Aim for PaCO2

Answer 8

38-40mmHg

Question 9

How to minimise increases in ICP after TBI

Answer 9

Raise head and neck by 15-30o from horizontal
- Use stiff board under the chest
- Increases venous drainage
Remove collars and check any wraps on venous catheters

Question 10

What is mannitol

Answer 10

Hyperosmolar drug
Used for severe TBI and progressive neurologic deterioration
Decreases ICP and improved CPP (cerebral perfusion pressure)
High dose shows better neurological improvements than low dose
Hypertonic saline may be better as lasts longer and reduced ICP more

Question 11

What does hyperglycaemia indicate after TBI

Answer 11

Reflects severity of injury
increases free radial production, excitatory amino acid release, cerebral oedema and cerebral acidosis, and alters the cerebral vasculature
Can be caused by steroid administration
Insulin infusions may help prevent detrimental effects

Question 12

Significance of hypothermia in TBI

Answer 12

Thought to decrease brain metabolic demands leading to decreased cerebral oedema and ICP

Question 13

How might hypothermia reduce secondary brain injury

Answer 13

Inhibition of post traumatic inflammatory response including reduction in release of inflammatory cytokines and preservation of the BBB

Question 14

Disadvantages to induced hypothermia after TBI

Answer 14

coagulation disorders
increased susceptibility to infections
hypotension
bradycardia
dysrhythmias
!! Complications occur with more severe hypothermia (<3OoC)

Question 15

Causes of hyperthermia after TBI

Answer 15

direct trauma to the thermoregulatory centre
excitement
seizure activity
pain
iatrogenic
!!!! AVOID
Increases cellular metabolism and vasodilation leading to increased ICP

Question 16

Risk factors to consider when treating TBI

Answer 16

severity of injury
depressed skull fractures
epidural, subdural and intra-cerebral haematomas
penetrating head wounds
seizure within the first 24 hours following injury

Question 17

Treatment options for TBI once stable

Answer 17

Analgesia
Anti-convulsant therapy- Prevention of posttraumatic seizures improves outcome
GI protectants- gastric ulcer prophylaxis

Question 18

Which drugs are used in anti-convulsant therapy

Answer 18

Diazepam regarded as drug of choice for stopping seizures
Use phenobarbitone for prevention

Question 19

Should steroids be used in small animal TBI

Answer 19

No as associated with:
Hyperglycaemia
Immunosuppression
Delayed wound healing
Gastric ulceration
Exacerbation of a catabolic state