Together We can take out the

Trauma from Traumatic Brain Injury

By: Amanda Di Florio RN, BN, CNCC(C)

Sandra Cook RN, BN, CNCC(C)

Potential Conflict of Interest

Disclosure

• Amanda Di Florio

• Sandra Cook

• I do not declare any potential conflict of

interest

The Brain Trauma Foundation

Introduction

• Approximately 18,000 hospitalizations associated

with TBI diagnosis annually in Canada Brain Injury Association of

Canada website at www.biac-aclc.ca

• 50,000 Canadians sustain brain injuries each year, • 50,000 Canadians sustain brain injuries each year,

and incidence rates are rising. www.torontorehab.com

• TBI’s accounted for 151.7 million in direct costs to

Canadians. Brain Injury Association of Canada website at www.biac-aclc.ca

Introduction

• Leading causes of TBI: (In U.S)

• Falls 35.2%

• Motor Vehicle – Traffic • Motor Vehicle – Traffic 17.3%

• Struck by- against events – 16.5%

• Assaults – 10%• http://www.brainline.org/content/2008/07/fact

s-about-traumatic-brain-injury.html

Mr. G.

• Mr. G. 18 y.o. No known PMHx.

• Daily ETOH use

• Mechanism of Injury:

• MVA hit a tree at 150 km per hour• MVA hit a tree at 150 km per hour

• Seat belt Utilised

• Air bag deployed

Mr. G. at the Scene….

• Presence of Urgence – Sante:

• GCS 13 on 15

• Becomes agitated and confused

• Stable BP, Tachycardia• Stable BP, Tachycardia

• Saturating at 100% on fio2: 100 % via

Rebreather

Mr. G.’s Injuries….

• Injuries:

• Right Ribs 3 to 7 #s - Left Ribs 3 to 5 #s

• Transverse Process # -

• Left Epidural Bleed with a midline Shift of 1.7 mm• Left Epidural Bleed with a midline Shift of 1.7 mm

• ETOH of High level

Golden Hour

• The time interval lasting for one hour from injury

to obtaining medical care.

• All patients must be transported so that they are

able to receive surgery within the first hours after able to receive surgery within the first hours after

injury.

• Prompt medical treatment will prevent death

Initial Assessment

• Primary Survey:

• Airway

• Breathing

• Circulation

• Secondary Survey:

• Signs and Symptoms

• Allergies

• Medication• Circulation

• Disabilities

• Medication

• Past medical history

• Last meal

• Events prior

Airway

• Unpredictable Clinical Course - Low threshold

for securing the airway.

• A Loss of Consciousness correlates with an

increased incidence of an acute intracranial increased incidence of an acute intracranial

injury.

• Potential Cervical Spine Injury

Oxygenation

• Keep O2Sat. greater than 90%

• Measured continuously with a

pulse oximeter

• Hypoxia to be avoided and • Hypoxia to be avoided and

immediately corrected d/t Higher

Mortality

• Supplemental O2, and airway

adjuncts

Who Does Not Benefit from

Intubation

• Ground transported pts. in urban environments,

• Spontaneously breathing, and maintaining an Spo2

above 90% on supplemental oxygen

• Without signs of active herniation• Without signs of active herniation

• Protects their own Airway

Why its not a Benefit….

• Increased risk of Hypoxia

• Bradycardia

• Prolonged scene time

• Inadvertent Hyperventilation after • Inadvertent Hyperventilation after

Intubation

Who Does Benefit from Endotracheal

Intubation

• Severe TBI with GCS Score of <8,

• Unconscious with ineffective ventilation

• Inability to maintain an adequate airway, no

gag reflexgag reflex

• Hypoxemia not corrected by supplemental

oxygen and adjunct airways

End-Tidal Co2 Monitoring

• Monitoring of ETCO2 is fundamental to TBI

management (if intubated).

• Lower incidence of Hyperventilation and

Lower MortalityLower Mortality

• Not only in the hospital but also in pre-

Hospital arena.

Limitations to ETCO2

• ETCO2 and PaCO2 levels correlates well in

healthy patients.

• Difference in PaCO2 and ETCO2 due to;

– Poly-Trauma– Poly-Trauma

– Severe chest trauma

– Hypotension

– Heavy blood loss.

Consequences of Hypotension..

• Keep Systolic Blood Pressure greater than 90mmHg

• Single episode of Hypotension Doubles mortality and

an increased morbidity.

• Increased risk of 30 day in-hospital mortality. • Increased risk of 30 day in-hospital mortality.

• More valuable to maintain Higher MAP than to

Maintain Systolic BP > 90mmHg

Hypotension in a TBI…

• Could be caused by a

Source of Major bleeding

elsewhere other than the

HeadHead

• Signs of Hemorrhagic

Shock treat as so…

Fluid Resuscitation

• Ringers Lactate or Normal Saline as initial fluid

bolus. (1 -2 Liters based on fluid/blood loss)

• Crystalloid fluid mostly used

• Hemoglobin substitutes • Hemoglobin substitutes

Hyperosmolar Therapy

• Treatment option for TBI with GCS less than 8

with active signs of Herniation

• Mannitol can be administered

• Can be used to Temporarily Decrease ICP before • Can be used to Temporarily Decrease ICP before

Surgical Intervention.

• No evidence to support its use in the pre-

hospital setting.

• If used inappropriately can increase mortality

Why do Glasgow Coma Scale Score

• A significant and reliable

indicator of the severity

• Frequent GCS ( q1hr and

prn) prn)

• To Identify improvement

or deterioration over

time.

• Obtain best Score

When to do a GCS Score

• After ABC’s are assessed

and managed.

• Pre and Post

administration of administration of

sedative or paralytic

agents.

Types of Painful Stimulus

• Sternal Rub – Avoid in chest trauma

• Trapezius pinch

• Supraorbital Pinch – Avoid if ocular facial

deformitiesdeformities

• Nail bed pain (peripheral stimulation)

Responses to Painful Stimulus

• Localizing - An organized attempt to Localize

and remove painful stimulus

• Withdrawing – withdraws extremity from

source of painful stimulussource of painful stimulus

• Decortication- abnormal flexion

• Decerebration – abnormal extension

• Flaccid

Decortication

- The Upper Arms

move towards the

Chest with Elbows,

Wrists and FingersWrists and Fingers

Flexed

- Legs extend with

Internal rotation

and the Feet Flex

Decerebration

- The Neck extends,

-The Jaw clenches, -The Jaw clenches,

- Arms Pronate and

extend straight out

- The feet plantar

flex

Why do a Pupillary Exam…

• Guide to immediate medical decision making

• Long term prognosticator in combination with physical findings.

• Strong correlation between fixed, dilated • Strong correlation between fixed, dilated pupils and ultimate mortality

• Pupil examination can be an indicator of anatomical location and severity of TBI

• 3rd cranial nerve compression from uncalherniation

When to Exam Pupils

• For use in diagnosis,

treatment, and

prognosis

• After the patient has • After the patient has

been resuscitated and

stabilized

• Before and After Opioid

administration

What to Observe in the Pupils….

• Size and Shape

• Symmetry

• Reaction to light in • Reaction to light in

both pupils.

• Light Reflex

Abnormal Pupillary Findings

• Unilateral or Bilateral dilated pupils

• Fixed and dilated Pupil(s)

• Asymmetry: Greater than one millimeter difference

• Asymmetry: Greater than one millimeter difference in diameter

• Fixed pupils: Less than one millimeter response to bright light

Mode of Transportation

• Selected to minimize total pre-hospital time.

• Ground ambulance versus helicopter

• Pre-hospital care providers select the

appropriate destination facility.appropriate destination facility.

• 7 % Decreased mortality when treated in a

Trauma Center compared to other hospitals.

Decision Making

• 70% decrease in mortality if patient

evaluation is performed within two hours of

injury.

• Those treated within 4 hours there was a 10% • Those treated within 4 hours there was a 10%

absolute reduction in mortality compared to

those treated greater than 4 hours.

• Outcomes are better with an Organized EMS

system for trauma Patients.

Use of Helicopters….

• A 9% reduction in Mortality for TBI patients transported by helicopter compared to ground ambulance.

• In the Baxt study, Helicopters were staffed by a MD and a RN, while the staffed by a MD and a RN, while the ground ambulance was staffed by a paramedic.

• Helicopter had better odds of survival, compared to ground transport, after controlling for a number of potential confounding variables.

Upon Arrival to MGH ER…..!!!!

• Adequate oxygenation: PaO2 >60 mmHg, Oxygen

sat. > 90%, Capnography

• Hemodynamics: Sys. BP > 90mmHg, Monitor

Heart Rate Heart Rate

• Temperature: (36.5 to 37.5)

• Neuro Exam ASAP: GCS score

• GCS less or equal to 8 = SEVERE TBI

• Risk of Deterioration until 72 hrs after injury!!!

Laboratory Workup

• Assess for other systemic trauma

• Complete Blood Count;(Hb, WBC)

• Electrolyte and Acid Base alterations, Glucose

• ETOH level, Toxicology screen

• Coagulation Fac. &Cross Match

• Correcting INR if applicable (FFP’s, Beriplex)

• Should be done by transferring hospital (when appropriate)

CT Head Stat…!!!

• Neuro Imaging

• Ct scan will detect:

• Skull #’s

• Intracranial hematomas • Intracranial hematomas

• Cerebral edema

• Neurosurgery consult

ASAP!

TBI Severity Score Scale

• Obtaining a CT scan

should not delay

patient transfer to a

trauma center

Types of Brain Injuries

• Blunt brain injury: automobile collisions, falls,

and assaults with blunt weapons

Types of Brain Injuries

• Penetrating brain injury: gunshots and stab

wounds

Epidural Hematoma

Types of Brain Injuries

Subdural hematoma Intracerebral hemorrhage

Types of Brain Injuries

Subarachnoid Hemorrhage Cerebral contusions

Diffuse Axonal Injury (DAI)

Signs of Increased ICP

Pt’s with suspected High ICP are at risk of Brain

Herniation!

• Signs and Symptoms:

• Unilaterally or bilaterally • Treatment:

• Head elevation • Unilaterally or bilaterally

fixed and dilated pupils

• Decorticate or Decerebrate

posturing

• Cushing’s Triad

• Decrease in LOC and GCS

• Head elevation

• Osmotic therapy

(Mannitol 1g/kg IV)

• Hyperventilation (CO2

between 30-35)

• Neurosurgical

intervention

Cushing’s Triad

• Systolic BP increases

• Widening pulse pressure (the difference

between systolic and diastolic BP)

• Bradycardia• Bradycardia

• Irregular breathing (such as Cheyne-Stokes)

Types of Brain Herniation

Admission to ICU

• Principal focus of critical

care management for

severe TBI is to limit

secondary brain injury

• Optimizing:

• Oxygenation

• Blood pressure

• Managing Temperature

• Treatment Priorities:

• ICP management

• Maintenance of CPP

• Managing Temperature

• Glucose

• Seizures

• Isotonic fluids (NS only)

(Never Dextrose!)

Monro-Kellie Doctrine

• Blood

• CSF

• Brain

• If increase in size of one compartment (ie: compartment (ie: hematoma)

• With no decrease in size from other compartments

• Then ICP will increase

Intracranial Pressure Monitoring

• Assist neurosurgeon with EVD insertion

• EVD allows monitoring of ICP and drainage of

CSF to decrease ICP

• Drain CSF to keep ICP < 20 mmHg • Drain CSF to keep ICP < 20 mmHg

• Codman (monitoring of ICP only)

Normal ICP waveforms

• Represents the Pulsation from in the Brain

from Intracranial Arteries and Veins.

Neurosurgical Interventions

• Craniotomy: bone flap is

temporarily removed from

the skull to access the

brain brain

• Burr Holes: a hole is drilled

or scraped into the skull,

exposing and penetrating

the dura mater

Neurosurgical Interventions

• Decompressive

Craniectomy:

• portion of skull removed in

order to reduce increased

ICP

*Caution! Do not turn the

patient onto the side of

Craniectomy - no skull!*

Hyperosmolar Therapy

• Mannitol 20% Hypertonic saline 3%

• Creates an osmotic gradient, drawing H20 across the blood-brain barrierblood-brain barrier

• Leads to decrease in interstitial volume and a decrease in ICP

• Monitor serum sodium and serum osmolality levels

Sedation

• Lowers ICP by reducing metabolic demand

• Sedation: Propofol, Versed, Fentanyl

• Assure that pain is well controlled (Fentanyl)!

• Propofol preferred for sedation: short duration of • Propofol preferred for sedation: short duration of

action (neuro exams), causes decreased cerebral

metabolic rate, can decrease ICP

Ventilation

• Maintenance of CO2 between 35 and 38 mmHg

• Hyperventilation: Should be avoided

Due to Vasoconstriction –• Due to Vasoconstriction –Impairs Cerebral Perfusion (CPP)

• Leads to Cerebral Ischemia (Secondary Injury)

Hemodynamics

• CPP = (MAP – ICP)

• CPP between 60 and 70

mmHg

• Vasopressors;

Levophed, VasopressinLevophed, Vasopressin

• Monitoring CVP’s

(administration of

fluids)

• Strict Intake and

Output.

Barbiturate Therapy

• Barbiturate coma:

• Used less often (Used only in severe cases of

ICP management issues)

• Decreases metabolic rate of brain tissue• Decreases metabolic rate of brain tissue

• Reduce spread of epileptic focus

• Decreases intracranial hypertension

Seizures

• Increase Metabolic demand on damaged brain tissue

and may aggravate secondary brain injury

• 15 to 25% of pt’s with severe TBI will have non-

convulsive seizures

• Seizure prophylaxis: Dilantin for 7 days• Seizure prophylaxis: Dilantin for 7 days

• If Seizure activity present, than continue anticonvulsive

medication

• EEG Monitoring; Continuous or 24 hour EEG.

Paralysis

• Rocuronium infusion:

• Monitoring the TOF (train of four) watching

for muscle twitching

• Ensure adequacy of Sedation Prior• Ensure adequacy of Sedation Prior

• Used when ICP is difficult to manage

Induced Hypothermia

• Should only be used with patients with elevated ICP

(cooling blanket)

• Prevents secondary brain injury

• Potential to reduce ICP • Potential to reduce ICP

• Provides Neuro-protection

• Danger of pt Shivering

• Ensure adequately sedated!

• Regular antipyretics can be used adjuvant to cooling

Glucose Management

• Maintain between 6-10 mmol/L

• Frequent capillary glucose check

• Intermittent Humulin R subcutaneously

• If persistent Hyperglycemia • If persistent Hyperglycemia

• May require need for continuous Insulin

infusion

Preventative Care

• DVT prophylaxis:

• Deltaparin, Fragmin, etc..

• Check with Neurosurgery for

appropriate time to start appropriate time to start

anticoagulation.

• Risks vs. benefits must be outweighed

• Use of Inferior Vena Cava Filter

Nutrition

• Dietician consult for feeding

ASAP.

• Under nutrition is associated

with higher mortality.

• Continuous Enteral Feeding

• Stress Ulcer Prophylaxis -

Famotidine

Vasospasm

• Onset typically 4 to 10 days after subarachnoid hemorrhage.

• Blood vessel spasm leads to vasoconstriction

• Causing tissue ischemia and • Causing tissue ischemia and tissue necrosis

• Symptomatic vasospasm or delayed cerebral ischemia is a major contributor to post-operative stroke and death.

Vasospasm

• Prevention:

• Calcium Channel

Blocker’s - Nimodipine

• Treatment:• Treatment:

• HHH Therapy:

Hypervolemia,

Hypertension,

Hemodilution

New Technologies

• Cerebral Oxygen

Monitoring

• Jugular Bulb Oximetry • Jugular Bulb Oximetry

(SjvO2)

• Brain Tissue Oxygen

Tension (PtiO2)

• Intracerebral

Microdialysis

Conclusion

• Continuous assessment is extreme importance.

• Complex patient population

• Slight changes can be significant.

• GCS and Pupil assessment have some degree of subjectivity subjectivity

• However, it should be reproducible and reliable!

• Neuro exam must not be Forgotten or Omitted

• Treat other Traumatic Injuries

• Continue ICP Monitoring (even in OR)

• Don’t delay transfer in order to do a CT Head.

Thank you!!!

• Dr. Andrew Beckett, Trauma Staff MGH

• Dr. Charles Couturier, Neurosurgery Resident

• Julie Kinnon R.N, Nurse Educator, ICU MGH• Julie Kinnon R.N, Nurse Educator, ICU MGH

• Colleen Stone R.N, Nurse Manager, ICU MGH

Questions?

References• Brain Trauma Foundation Online TBI Guidelines, 2010.

• Brain Trauma Foundation, “Pre Hospital Emergency Care”, January, March 2007, Vol. 12, Number 1.

• Caroline, Nancy L. Emergency Care in the Streets, 5th Edition, 1995.

• Emergency Nurses Association “Trauma Nursing Core Course” Sixth Edition, 2007.

• Hernando, R. A-M., Castellar-Leones, S. M., & Moscote- Salazar, L.R., “Intravenous Fluid Therapy in Traumatic Brain Injury and Decompressive Craniectomy” Bullitin of Emergency and Trauma, 2014; 2(1):3-14.

• Hemphill and Phan, UpToDate “Management of Acute Severe Traumatic Brain Injury” 2013.

• Guidelines for the Pre-Hospital Care of Patients with Severe Head Injury. Intensive Care Med. (1998) 24: 1221 -1225.

• Kiehna, E. N., Huffmyer, J. L., Thiele, R. H., Scalzo, D.C., & Nemergut, E. C. “Use of the Intrathoracic Pressure regulator to lower Intracranial Pressure in Patints with altered Intracranial Elastance: A Pilot Study. J. Neurosurg, September 2013. Vol. 119: 756 – 759.

• Kaplow and Hardin “Critical Care Nursing” 2007.

• Wagner, K. D., Johnson, K. L., and Hardin-Pierce, M. G., High- Acuity Nursing, 5th Edition, 2010.

• Metheny, Norma M., Fluid and Electrolyte Balance Nursing Considerations, 4th Edition, 2000.

• Urden, L.D., Stacey, K.M., Lough, M.E., Thelan’s Critical Care Nursing Diagnosis and Management, 5th Edition, 2006.

• Topping, Claude. & Ducharme, James. “Prehospital Intubation for Patients with severe head injury: More is not necessarily better” CJEM Journal Club. March 2008; 8 (2).

• Tolias, C., Wyler, A. R., Initial Evaluation and Management of CNS Injury, Medscape References, (2013, September).

• Schimpf, Melissa M. “Diagnosing Increased Intracranial Pressure” Journal of Trauma Nursing, July-September 2012.

• Shirley, I. Stiver,. & Geoffrey, T. Manley., “Pre- Hospital Management of Traumatic Brain Injury” NeuroSurg Focus, 2008: 25 (4):E5.

• Smith, E. R., Amin-Hanjani, S., Aminoff, M. J. , & Wilterdink, J. “Evaluation and Management of Elevated Intracranial Pressure in Adults” Up to Date. 2013.

• http://biac-aclc.ca/2011/03/17/the-brain-injury-association-of-canada-supports-governments-investment-to-injury-prevention/