Treatments + Goals

Question 1

TBI Goals

Answer 1

• MAP >80 - use levo - use art line
• SBP <160 - use NIBP
• Temp 36-37.5
• PaCO2 35-45
• PaO2 >100
• Hgb >90

Question 2

SAH 85% aneurysmal - the rest due to malformations, cocaine etc

Answer 2

1. prevent rebreeding - SBP>140
   
   2. seizures - NO routine prophylaxis -
   3. hydrocephalus - obstruction of ventricles = regular ICP managment
   4. arrhythmias - long QT, optimize Mg+ and K+ levels
   5. Na+ disorders
      
      • DI - replace ADH with DDAVP 2mcg q 12hr or vasopressin at 0.03units/min
      • SIADH - fluid, decreased Na+ then use Hypertonic saline 50-100cc/hr
      • CSW - fluid resus - flutocortsone - 0.1-0.3mg/day + fluid + decreased Na+ then use Hypertonic saline 50-100cc/hr
   6. vasospasm = we will likely not mange - 3 days out from injury milrinone + CCB and statins

Question 3

How to treat Na+ Disorders in SAH

Answer 3

. Na+ disorders

    * DI - replace ADH with DDAVP 2mcg q 12hr  or vasopressin at 0.03units/min 
    * SIADH -  fluid, decreased Na+ then use Hypertonic saline 50-100cc/hr 
    * CSW - fluid resus - flutocortsone - 0.1-0.3mg/day  +  fluid  +  decreased Na+ then use Hypertonic saline 50-100cc/hr

Question 4

heads: DAI management

Answer 4

• can take your time to optimize **unless complicated by SUBDURL OR EPIDURAL
• increase PaO2
• optimize MAP, hgb, temp, Na+,
• hypertonic saline & mannitol = can help

Question 5

Status Seizure Tx:

Answer 5

• status - benzos IV - then Phenytoin 20mg/kg or keppra (PO) 500-1000mg down OG (NOT FOR SIEZURES DUE TO TOXIC OVERDOSES)
• refractory - add Propofol (or Midaz infusion 10mg/hr)
• super refractory - add Ketamine 10-100mg/hr or Barbituates
• others: magnesium - 5g/over 20 min infusion - potent anti epileptic + important co-factor
• temp: +/- active cooling
• verapamil: keeps phenytoin in the cell
• ketogenic diet

Question 6

Spinal Cord Injury Tx

Answer 6

• dopamine useful in spinal cord injury - has a, b, and dop
• MAP >85
• take time to optimize
• normal PaO2

Question 7

Ischemic Stroke Managment:

Answer 7

• TPA doses - weight based - CONTRAINDICATIONS: PREV SURGERY, BLEEDS, AGE <18 & >75, PREVIOUS CVA - don’t do by memory
• systemic lysis if <4.5 hrs
• lysed= SBP<180
• not lysed = SBP <220
• HOB zero degrees
• 1L fluid bolus
• increase FiO2 to increase PaO2 - ex: 4lpm