Bader Traumatic Brain Injury Thurs 900 am...Theories on Brain Compartment 80% brain 10% blood 10%...

11/26/2014

1

Neuro PROTECTion in Severe Traumatic Brain Injury

Presented by:

Mary Kay Bader RN, MSN

CCNS, CNRN, CCRN, SCRN, FAHA, FNCS

Neuro/Critical Care CNS

Mission Hospital

[email protected]

Disclosures

� Bader� Honorarium

� Bard, Neuroptics, & The Medicines Company

� AANN: Immediate Past President

� NCS Board of Directors

� Stock Options: Neuroptics

� Medical Advisory Board� Brain Trauma Foundation

� Neuroptics

PROTECT - ION

�� P P = Physiologic Changes from TBI

��RR = Resuscitation

��OO = Operative Intervention

��T T = Technology

�� EE = Entry to ICU

�� CC = Coordinated Care/Clinical Guidelines

��TT = Teamwork & Family Centered Care

Traumatic Brain Injury

Pathophysiology and Management

Classification

� Pathological Mechanisms� Direct � Indirect

� Mechanism of Injury� Blunt

� Falls� MVAs� Struck by object

� Penetrating -90% die

� Compression� Blast

Classification by Age Group - Mechanism

http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/s6005a1f5.gif

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Classification of Head Injury:Presentation

Primary Head Injury

� Occurs at the time of injury� Compromised skull integrity

� tearing of vessels/sinuses� dural tears� brain contusions� cranial nerve injuries

� Compromised brain integrity� linear and rotational forces

� Prevention is paramount to alter primary injury

PPhysiology Changes in Brain Injury

� Primary Injury

� Skull integrity� Fractures

� Basilar

� Depressed’

� Linear

Primary Injury: Epidural Hematoma


� Primary Injury

� Subdural hematoma

�Focal injuries

�Diffuse injuries

Cerebral Contusions

� Types:� Fracture

� Coup

� Countercoup

� Herniation

� Surface

� Gliding (focal hemorrhage in cortex/subjacent white matter found in DIA

� Frequently frontal or temporal regions

� Vasogenic edema and central necrosis

� Diagnosis: CT and Exam

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Diffuse Axonal Injury

� Extensive disruption of axons/white matter in both hemispheres

� Stress of gray-white interface

� Petechial hemorrhages

� Axonal shearing/swelling

� Diagnosis: CT and exam

Primary Head Injury

� Results of compromised brain integrity and cellular changes� cerebral edema

� hemorrhage/hematomas

� herniation

� brain death

Secondary Injury: Alteration in CBF

� Numerous studies have found low CBF in early hours after TBI

� Martin et al study on CBF in TBI� 1st 12 to 24 hours: Hypoperfusion/decrease in CBF

� 24 hours to Day 5: CBF exceeding CMRO2

� Days 5/6 to 14: Slow flow due to vasospasm

� CBF altered but it must be balanced with metabolism and oxygenation


Secondary Injury

�Extracranial causes�Hypotension�Hypocapnia and Hypercapnia�Hypoxia�Anemia�Acidosis�Hyperglycemia�Hyperthermia

Cerebral Blood FlowAutoregulation

�Vasomotor control�Intact: Increase in CPP causes

vasoconstriction and decrease in ICP�Vasomotor reactivity failure: Increase

in CPP causes vasodilation and inc ICP

�Flow metabolism�↑ metabolism ↑ CBF

�Metabolic substances�PaO2�PaCO2�pH i.e., acidosis = vasodilatation

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PPhysiologic Changes:Intracranial Pressure

� Theories on Brain Compartment� 80% brain

� 10% blood

� 10% CSF

� If one increases the other two decrease

� Compensatory mechanisms

SDH

80%10%

10%

Brain moves over

CSF shunts to spine SAS

Venous blood to heart

Symptoms of Increased ICP: Adults

� Early� Altered level of consciousness, restless,

agitated, headache, nausea, and contralateral motor weakness

� cranial nerves III and VI

� Late� Coma, vomiting, contralateral hemiplegia,

and posturing

� Alteration in Vital Signs

� Impaired brainstem reflexes� Pupils, dysconjugate gaze

RResuscitation

Arrival: Emergency Department Trauma Bay

Assess A-B-C: Oxygenation and Ventilation

Airway: Secured with RSI

Breathing: Connect to Ventilator

Avoid hyperventilation

Use Capnography to monitor ET CO2

Assess Circulation: Pulse, ECG and BP

�Hypertonic Saline� Posturing� Fixed non-reactive pupil

�Fluid Resuscitation� IV fluids to maintain adequate MAP 80

mm Hg

�Arterial line/Foley/OG

RResuscitationSevere TBI Patient: GCS 3-8 CT+ Injury

Arrival: Emergency Department Trauma Bay

RResuscitationSevere Brain Injury Algorithm

� CT scan

� OR Priorities

� Vent:100% FIO2 and PaCO2 35-45

� Place PA catheter; PbtO2; ICP

� Optimize MAP > 90 mm Hg� Fluids

� Correct coagulopathies

� Propofol to reduce CMRO2/ICP

OOperative Intervention

� Operative Intervention as indicated� Removal of SDH/EDH

� Craniectomy

� Placement of monitors

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OOperative InterventionSevere TBI Patient: GCS 3-8 CT+ Injury

OOperative InterventionSevere TBI Patient: GCS 3-8 CT+ Injury

TTechnology

� Technology� Place ICP monitor

� Treat for ICP > 20 mm Hg

� Clinicians should use a combination of ICP, clinical and brain CT finding to guide treatment

� Consider placement of PbtO2 monitor and treat PbtO2 < 15 mm Hg

� Place Hemodynamic Monitors and Regulate CPP 50-70 mm Hg

TechnologyIntracranial Pressure

� Normal range � 0-15 mm Hg

� Abnormal ranges� moderate 20-40

� severe > 40

Technology Oxygenation

Delivery of oxygen to the brain dependent on Lungs

Hemoglobin and PlasmaPreload (CVP) /Cardiac Output/ Afterload

(SVR)CBF = CPP/CVR

Autoregulation

Vasomotor control

Flow Metabolism↑metabolism/flow ↓metabolism/flow

Chemical

PaCO2 / PaO2 / pH

TTechnologyOxygen Dynamics:

Brain Tissue Oxygen Monitoring

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TTechnologyBrain Tissue Oxygen(Pbt02)

� Normal: 20-40 mm Hg

� Risk of death increases� < 15 mm Hg for 30 minutes

� < 10 mm Hg for 10 minutes

� PbtO2 < 5 mm Hg � high mortality

� PbtO2 < 2mm Hg - neuronal death

TTechnologyBrain Tissue Oxygen(Pbt02)

� Decreasing PbtO2� Hypoxia

� Low Hemoglobin

� Decreasing PaCO2

� Increased ICP

� Decreased MAP/CPP

� Shivering

� Vasospasm

� Systemic Causes� Pulmonary

� Cardiac/Hemodynamic

� Increasing PbtO2� Increasing FIO2 when

PaO2 < 80 mm Hg

� Increasing Hemoglobin

� Increasing PaCO2

� Draining CSF

� Increasing CPP/MAP

� Control shivering

� Barbiturates

Outcomes: TBI

41 pts (1998-2000) vs 139 (2000-

2005)

CPP & PbtO2

EEntry into the ICU

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CCoordinated CCare BTF: Core TBI Management

� Place ICP and cerebral ischemia monitor

� Core interventions� Drain CSF

� CO2 35-45 mm Hg

� Sedation/Analgesia

� Normothermia T 37

� CPP 50-70 mm Hg

BTF 2007 Severe TBI Guidelines

� BP & Oxygenation

� Hyperosmolar Tx

� Prophylactic Hypothermia

� DVT Prophylaxis

� Indications for ICP Monitoring

� ICP Monitoring Technology

� ICP Thresholds

� CPP Thresholds

� Brain Oxygen Monitoring &Thresholds

� Anesthetics, Analgesics, & Sedatives

� Nutrition

� Anti-Seizure

� Hyperventilation

� Steroids

CCoordinated CCare/CClinical Guidelines

Intensive Care Unit

A & B: Oxygenation/Ventilation Optimization Target PaCO2: 35 mm Hg (Day 1) & 30-35 (Days2-5)

Circulation: Maintain CPP 50-60 mm Hg as initial target

Autoregulation Testing: Intact – may need CPP to 70 mm Hg

Mannitol/Hypertonic Saline

ICP Management:

Draining CSF and Providing Sedation/Analgesia

Normothermia

CCoordinated CCare CClinical Guidelines

� Tertiary Interventions� Mild Hypothermia

� Decompressive Hemicraniectomy

� Barbiturate Coma� Not used much in US

TTeamworkPutting It All Together

Real World Real Patients

TTeamworkFamily Focused Care

� The healthcare team can impact patients outcome by actively engaging families in care: Family Focused Care

� Providing FFC requires assessment, planning, intervention, and evaluations for each unique family� Assurance, Proximity to Patient,

Information, Comfort and Support

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Teamwork: MD Protocols

Teamwork: MD Protocols

TTeamworkPrimary Interventions: Airway

� Assessment of Oxygenation/Ventilation� Patency of airway� Intervene: Rapid Sequence Intubation

� Oxygenation� Ventilation

� 1st 24 hours: PaCO2 35-45 mm Hg� If…Increased ICP PaCO2 30-35 mm Hg

� Influence of Airway/Ventilation

Issues Day 1� Pulmonary worsens

with PaO2 131 to 54� PbtO2 24 drops to 11

mm Hg

� ICP ↑35 mm Hg

– Low PbtO2 correlating with low PaO2

– Leads to Inc ICP

PbtO2 8 mm Hg

TTeamworkPrimary Interventions:

Circulation� Optimize CPP: Find the

right place

� Goal 50-70 mm Hg � Fluids: SVV < 13%

� Vasopressor support once euvolemic

Interventions: Circulation

�Neck midline

�Head of Bed�Flat if hypovolemic –

temporary measure

�30 degrees if euvolemic

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TTeamworkPrimary

Intervention: Intracranial

PressureCSF Drainage

� Normal range

� 0-15 mm Hg

� Abnormal ranges

� > 20 mm Hg

� Compliance waveform analysis

TTeamworkPrimary Intervention: Optimal

Sedation /Analgesia

� Analgesia� Fentanyl

� Sedation� Propofol

� Benzodiazepines

� Dexmedetomidine

TTeamworkPrimary

Intervention

Normothermia

&

Shivering

Step-Wise Managementof Shivering

TTeamworkSecondary/Tertiary

Interventions

� Secondary Interventions� HTS

� Mannitol

� Tertiary Interventions� Pentobarb coma

� Decompressive hemicraniectomy

� Mild Hypothermia

Interventions: Systemic

� Bundles� Infection prevention

� Ventilator� Foley� Central Line

� GI: �OG for gastric decompression�Stress ulcer prophylaxis�Nutrition: caloric goal by day3

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Interventions: Mobility

� Musculoskeletal� Early Mobility Program

START HERE

MOVEN SCREEN � Perform initial mobility

screen within 8 hrs of ICU

admission AND reassess

every 12 hours

� Report at MDR daily (RN,

RT, PT)

� Refer to the following

criteria in determining

mobility level:

M: Myocardial stability

• 50 < HR* < 120

• 90 < SBP* < 200

• 55 < MAP* < 120

*or normal range for pt

• No active ischemia x 24 hrs

• No new IV antidysrhythmic

agents x 24 hrs

O: Oxygenation

• FiO2 ≤ 60%

• PEEP < 12

• SPO2 ≥ 92% (88% with

activity)

• 10 < RR < 35

V: Vasopressor(s) minimal

• No increase in vasopressor

infusion in last 2 hrs

E: Engages to voice

• Pt opens eyes to verbal

stimulation

N: Neurologic stability

• ICP <20mmHg

• Absence of active seizures x

24hrs

CONTRAINDICATIONS:

• Unstable fx

• Active bleeding

• Active fluid resuscitation

• Open chest/abdomen

Includes complex, intubated, hemodynamically unstable and

stable intubated patients; may include non-intubated.

Includes intubated, non-intubated and hemodynamically

stable/stabilizing, no contraindications.

LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V

RASS -5 TO -3 RASS -3 AND UP RASS -1 AND UP RASS 0 AND UP RASS 0 AND UP

Goal: Passive ROM;

Initiate nutrition within

24 hrs

Goal: Upright sitting;

Increased strength;

Move arms against

gravity

Goal: Increased trunk

strength; Move legs against

gravity and readiness to

weight bear; Ability to

perform some ADL’s with

assist

Goal: Stand with assist;

March in place and

transfer to chair

Goal: Increase

ambulation distance

Activity:

• HOB ≥ 30o

• Passive ROM 3x/day

by RN, PCT or family

• Turn Q 2hr

• Cycle ergometry (as

determined by PT)

Consults:

• Dietician Consult

• PT Consult for cycle

ergometry and family education board

recommendations

• ST Consult for coma

stim and family

education board recommendations

Begin Family Education

Board

Activity:

• Full chair position 3x/day x 30 min

• Passive ROM

3x/day by RN, PCT

or family

• Turn Q 2hr

• Cycle ergometry (as determined by PT)

Consults:

• PT Consult if not

already following

• OT Consult PRN

(i.e., neuro, splinting

needs)

• SP Consult if pt has trach

Activity:

• Self or assisted turning Q 2hr

• Sitting EOB with RN, PT,

OT x 15 min

• Full chair position

3x/day x 45-60 min

• Begin transfer to chair via Sabina lift

• Passive ROM/begin to

encourage AAROM

3x/day by RN, PCT or

family


determined by PT)

Consults:

• OT Consult

• SP Consult if extubated

and not already

following

ARU Consult (if consistently

participating with therapy and

able to follow commands)

Activity:

• Active transfer OOB to chair with RN, PT, OT

3x/day x 30 min (meal time)

• Sitting on EOB/stand

at bedside with RN,

PT, OT

• Self or assisted

turning Q 2hr


3x/day x 60 min

• Encourage

AAROM/AROM

3x/day with RN, PCT,

PT, OT or family


determined by PT)

Consults:

• ARU Consult

Activity:

• OOB to chair 3x/day with RN,

PCT, PT, OT x 60 min

• Ambulate

progressively

longer distances 2-

3x/day with RN, PCT, PT, OT

• Cycle ergometry

(as determined by

PT)

*For each position/activity change, allow 5-10 min for equilibration before determining the patient is intolerant.

**If the patient is intolerant of current activity level, reassess and place in appropriate mobility level.

MDR: Multidisciplinary Rounds EOB: Edge of Bed

PROM: Passive Range of Motion AAROM: Active-Assisted Range of Motion

AROM: Active Range of Motion ADL’s: Activities of Daily Living

Tolerates Level I activities, progress

to Level II.

Tolerates Level II

activities, progress

to Level III

Tolerates Level III


to Level IV.

Tolerates Level IV

activities, progress to Level V.

Guidelines for Early Mobility

• Levels

– Levels I-II-III• Complex, intubated, hemodynamically unstable and stable

intubated patients

• May include non-intubated

– Levels III-IV-V• Intubated, non-intubated and hemodynamically


• For each position/activity change, allow 5-10 min for equilibration before determining the patient is intolerant.

• If the patient is intolerant of current activity level, reassess and place in appropriate mobility level.

stable intubated patients; may include non

LEVEL I

RASS -5 TO -3

Goal: Passive ROM;

Initiate nutrition within

24 hrs

Activity:

• HOB ≥ 30o

• Passive ROM 3x/day

by RN, PCT or family

• Turn Q 2hr


determined by PT)

Consults:

• Dietician Consult

• PT Consult for cycle

ergometry and family

education board

recommendations

• ST Consult for coma

stim and family

education board

recommendations

Begin Family Education

Board

*For each position/activity change, allow 5

Tolerates Level I


to Level II.

Level I• RASS -5 to -3

Level II• RASS -3 and UP

stable intubated patients; may include non-intubated

LEVEL II

RASS -3 AND UP


Increased strength;

Move arms against

gravity

Activity:


3x/day x 30 min

• Passive ROM

3x/day by RN, PCT

or family

• Turn Q 2hr


determined by PT)

Consults:


already following

• OT Consult PRN


needs)

• SP Consult if pt has

trach

Tolerates Level II


to Level III

Level III

• RASS -1 and UP

intubated. stable/stabilizing, no contraindications

LEVEL III

RASS -1 AND UP






assist

Activity:

• Self or assisted turning

Q 2hr


OT x 15 min


3x/day x 45-60 min

• Begin transfer to chair

via Sabina lift


encourage AAROM


family


determined by PT)

Consults:

• OT Consult


and not already

following




10 min for equilibration before determining the patient is intolerant.

Tolerates Level III


to Level IV.

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Levels IV and V• RASS 0 and UP


LEVEL IV LEVEL V

RASS 0 AND UP RASS 0 AND UP


March in place and

transfer to chair

Goal: Increase

ambulation distance

Activity:

• Active transfer OOB to

chair with RN, PT, OT

3x/day x 30 min (meal

time)


at bedside with RN,

PT, OT


turning Q 2hr


3x/day x 60 min

• Encourage

AAROM/AROM


PT, OT or family


determined by PT)

Consults:

• ARU Consult

Activity:

• OOB to chair

3x/day with RN,

PCT, PT, OT x 60

min

• Ambulate

progressively

longer distances 2-

3x/day with RN,

PCT, PT, OT

• Cycle ergometry

(as determined by

PT)

Tolerates Level IV


Nursing Strategies for Neuro

PROTECT - ION�� P P = Physiologic Changes from TBI

�� RR = Resuscitation

�� OO = Operative Intervention

�� T T = Technology

�� EE = Entry to ICU

�� CC = Coordinated Care/Clinical Guidelines

�� TT = Teamwork & Family Centered Care

�� I I – Individualize Care!

��O O – Outcomes must be measured and analyzed!

��NN – Nuances: What have you learned as a team?

Individualize Care� Each patient is unique!

� Responses to injury vary

Outcome Measurement in TBI

Case Study

Case Overview

� 30 year old male involved in altercation falls backwards/strikes head

� Arrival in ED as a Trauma� GCS 3 with fixed non-reactive pupils at

5 mm bilateral

� Intubated with 7.5 ET/Foley/OG

� IV � Mannitol 100 grams IV

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CT

4/6/19834/6/1983

Page: 13 of 217Page: 13 of 217

Acq No: 2Acq No: 2KVp: 120KVp: 120mA: 223mA: 223Tilt: -8Tilt: -8RD: 217RD: 217

BRAIN WO STBRAIN WO ST

11/15/2013 6:52:37 PM 11/15/2013 6:52:37 PM

C T20131115-0111C T20131115-0111

LOC : 1717.30LOC : 1717.30

C ompressed 11:1Compressed 11:1

Jakishev, Amirzhan AJakishev, Amirzhan A

AR01001691AR01001691

4/6/19834/6/1983


Acq No: 2Acq No: 2KVp: 120KVp: 120mA: 218mA: 218Tilt: -8Tilt: -8RD: 217RD: 217

MIssion AS64 MIssion AS64

CT Brain Head wo ContrastCT Brain Head wo Contrast


11/15/2013 6:52:37 PM 11/15/2013 6:52:37 PM

CT20131115-0111CT20131115-0111

LOC: 1722.30LOC: 1722.30

Compressed 11:1Compressed 11:1

AAAR01001691AR01001691

4/6/19834/6/1983

Acq No: 2Acq No: 2KVp: 120KVp: 120mA: 206mA: 206

RD: 217RD: 217

C T Brain Head wo C ontrastC T Brain Head wo Contrast


11/15/2013 6:52:38 PM 11/15/2013 6:52:38 PM

C T20131115-0111CT20131115-0111

LOC : 1737.30LOC: 1737.30

Acq No: 2Acq No: 2


11/15/2013 6:52:40 PM 11/15/2013 6:52:40 PM

CT20131115-0111CT20131115-0111

LOC: 1752.30LOC : 1752.30

159.63mm159.63mm

18.76mm18.76mm

CT20131115-0111CT20131115-0111

LOC: 1777.30LOC: 1777.30

Operating Room

� Preop Diagnosis� Left Subdural Hematoma

� Sagittal suture diastasis

� Procedure� Evacuation of L SDH

� Left craniectomy

� Placement of ICP/PbtO2

� EBL: 1 liter

Jakishev, Amirzhan A

AR01001691AR01001691 MIssion AS64

CT Brain Head wo ContrastCT Brain Head wo Contrast

BRAIN WO ST H45sBRAIN WO ST H45s

11/17/2013 5:00:45 AM 11/17/2013 5:00:45 AM

CT20131117-0001CT20131117-0001

LOC: -783.30LOC: -783.30

A


Acq No: 3Acq No: 3KVp: 120KVp: 120mA: 257mA: 257Tilt: -14RD: 233RD: 233

11/17/2013 5:00:46 AM 11/17/2013 5:00:46 AM

CT20131117-0001CT20131117-0001

LOC: -768.30LOC: -768.30

IM: 19 SE: 3IM: 19 SE: 3Compressed 11:1Compressed 11:1

PP

C T20131117-0001CT20131117-0001

LOC : -753.30LOC: -753.30

LOC: -738.30LOC: -738.30

Page: 30 of 211 Compressed 11:1

To SICU

� Arrived 2230 Transported on 100% from OR� MAP 93 – ICP 10 = CPP 82

� PbtO2 50 PaCO2 42 PaO2 379

� FIO2 titrated down to 50% within 1 hour

SICU Day 1-2

� ICP 10 to low 20s � MAP 75 ICP 10-22

PbtO2 20-25 mm Hg

� Tx Hypertonic Saline

� Pupillary reaction improving� CS -1.0-0.8 mm/sec

in R

� CS 0.5-0.2 mm /sec in L

MAP

ICP

CPP

PbtO2

R CV

L CV

Improvement if goes in this direction

Day 3: Assessment for MOVEN

� Pt intubated/ventilated

� Sedated RASS -4� Versed & Fentanyl

� ICP requiring drainage

� Assessed for MOVEN� Phase I

� Ready for ergometry evaluation

Safety Screening (Patient must meet all criteria)

MOVEN SCREENRefer to the following criteria in determining mobility level:

M: Myocardial stability50 < HR* < 12090 < SBP* < 20055 < MAP* < 120 *or normal range for ptNo active ischemia x 24 hrsNo new IV antidysrhythmic agents x 24 hrs

O: OxygenationFiO2 ≤ 60%PEEP < 12SPO2 ≥ 92% (88% with activity)10 < RR < 35

V: Vasopressor(s) minimalNo increase in vasopressor infusion in last 2 hrs

E: Engages to voice ----------- ORPt opens eyes to verbal stimulation

N: Neurologic stability ICP <20mmHgAbsence of active seizures x 24hrsCONTRAINDICATIONS:Unstable fxActive bleedingActive fluid resuscitationOpen chest/abdomen

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Focused Mobility with Team Day 4

Before Ergometry

After 20 minutes into Ergometry

ICP

ICP

PbtO2

PbtO2

ICU Course – Days 3-7

ICP controlled with periodic spikes above 20

PbtO2 range 20-35 mm Hg

Day 5 MobilityBefore Ergometry

After 20 minutes into Ergometry

ICP

ICP

PbtO2

PbtO2

Notes PT Day 6

Days 6-8

� Weaning sedation

� ICP controlled / VS stable

� Continues with ergometry

Nurse Note Day 7

Nurse Note Day 8

PT Note Day 10

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Progress from Level I to II

stable intubated patients; may include non-intubated

LEVEL II

RASS -3 AND UP


Increased strength;

Move arms against

gravity

Activity:


3x/day x 30 min

• Passive ROM

3x/day by RN, PCT

or family

• Turn Q 2hr

• Cycle ergometry (as determined by PT)

Consults:


already following

• OT Consult PRN


needs)

• SP Consult if pt has

trach

Tolerates Level II


to Level III

PT Note Day 11

Days 10-14� Weaning sedation

� ICP controlled / VS stable� Day 10 ICP & PbtO2

D/C

� Weaned from Vent� 1st extubation Day 8

fail due to secretions

� 2nd extubation Day 13

� Continues with ergometery

Nurse Note Day 10

Nurse Note Day 14

Days 14 Level III

intubated. stable/stabilizing, no contraindications

LEVEL III

RASS -1 AND UP






assist

Activity:

• Self or assisted turning

Q 2hr


OT x 15 min


3x/day x 45-60 min

• Begin transfer to chair

via Sabina lift


encourage AAROM


family


determined by PT)

Consults:

• OT Consult


and not already

following




10 min for equilibration before determining the patient is intolerant.

Tolerates Level III


to Level IV.

Days 14-25

� Progress with strengthening but has ++ secretions

� GCS improves from 3-5-1T on Day 14 to 4-6-1T by Day 25

� Increasing interaction with family and nurses

� PT/OT/ST working with patient 2x per day each service

PT Note Day 23

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Progressing Level IV-V


LEVEL IV LEVEL V

RASS 0 AND UP RASS 0 AND UP


March in place and

transfer to chair

Goal: Increase

ambulation distance

Activity:

• Active transfer OOB to

chair with RN, PT, OT

3x/day x 30 min (meal

time)


at bedside with RN,

PT, OT


turning Q 2hr


3x/day x 60 min

• Encourage

AAROM/AROM


PT, OT or family


determined by PT)

Consults:

• ARU Consult

Activity:

• OOB to chair

3x/day with RN,

PCT, PT, OT x 60

min

• Ambulate

progressively

longer distances 2-

3x/day with RN,

PCT, PT, OT

• Cycle ergometry

(as determined by

PT)

Tolerates Level IV


1 month � Pt has no insurance

� Case Manager working on arrangements for ARU for 4 weeks (Began working on case early in hospital stay)

Nurse Note Day 30

Nurse Note Day 34

Nurse Note Day 40

Outcomes

� Transferred to PCSU on Day 43

� Admitted to ARU on Day 53� By Day 61: independent in bed mobility, improved

transfer, able to walk 150 ft with supervision/contact guard assist; ADLs supervised; cognition overall moderate assist

� Cranioplasty completed on Day 61� Complicated by EDH develop Post op day 1- return

to OR for evacuation

� Transferred to ARU Day 68 to complete ARU

� Discharge home on Day 76� Ambulating 175 feet; ADLs supervised; Cognition – minimal

assist for attention to task; Problem solving min assist level

Conclusion

Bader Traumatic Brain Injury Thurs 900 am...Theories on Brain Compartment 80% brain 10% blood 10%...

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Transcript of Bader Traumatic Brain Injury Thurs 900 am...Theories on Brain Compartment 80% brain 10% blood 10%...