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Guidelines for the Management of Severe Traumatic Brain Injury PowerPoint Presentation

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Description : Check out this medical presentation on Neurology, which is titled "Guidelines for the Management of Severe Traumatic Brain Injury", to know about Traumatic brain injury (TBI) and its Management.

Tags : Neurology, Guidelines, Management, Severe Traumatic Brain Injury

Published on : Aug 23, 2021 | Views : 1836 | Downloads : 3

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Slide 1-

Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition R2 Chanpitcha Khumchoei R2 Sithee Chumthong Advisor : Ajarn.Parichat Nilyam
Slide 2-

Introduction
Slide 3-

Severity of traumatic brain injury
Slide 4-

Quality Assessment of Individual Studies
Slide 5-

Level of Recommendation
Slide 6-

Scope of the guideline
Slide 7-

PART I : TREATMENTS
Slide 8-

Decompressive Craniectomy Cerebral edema primary injury secondary injury DC : relieving elevated intracranial pressure variations in surgical techniques timing patient populations
Slide 9-

Decompressive Craniectomy Recommedations
Slide 10-

Decompressive Craniectomy Recommedations
Slide 11-

Hypothermia Hypothermia Prophylactic : early after injury and prior to intracranial pressure elevation Therapeutic : treatment for refractory intracranial pressure elevation
Slide 12-

Prophylactic Hypothermia Hypothermia : Preserve cells and tissue Standard care for neuroprotection after cardiac arrest from acute coronary syndromes Hypothermia bears risks Coagulopathy Immunosuppression Cardiac dysrhythmia Death
Slide 13-

Prophylactic Hypothermia Recommendations
Slide 14-

Hyperosmolar Therapy Dramatic change of the volume of the brain : administration of hypertonic or hypotonic intravenous solutions Previous routine management : intracranial hypertension and herniation syndromes Hypertonic saline and Mannitol : Osmotic diuretic of the brain Hypertonic saline Central pontine myelinolysis Mannitol diuretic effect is undesirable in hypotensive patient
Slide 15-

Hyperosmolar Therapy Recommendations
Slide 16-

Cerebrospinal Fluid Drainage External ventricular drainage (EVD) : controversy EVD closed position : monitor intracranial pressure (CP) open position : drainage of CSF
Slide 17-

Cerebrospinal Fluid Drainage Recommendations
Slide 18-

Ventilation Therapies Definitive airway protection risk of pulmonary aspiration compromised respiratory drive and function transient hyperventilation The goal for severe TBI patients Normal ventilation and normal partial pressure of carbon dioxide in arterial blood (PaCO2) ranges from 35-45 mm Hg Cerebral blood flow : The brain’s metabolic demands Low PaCO2 : low CBF  cerebral ischemia High PaCO2 : cerebral hyperemia  high intracranial pressure (ICP)
Slide 19-

Ventilation Therapies Older studies : cerebral hyperemia > cerebral ischemia  suggest hyperventilation Recent studies : cerebral metabolic rate is variable Cerebral ischemia has been largely documented after severe TBI High prevalence of cerebral ischemia suggests safety in providing normoventilation
Slide 20-

Ventilation Therapies Recommendations Recommendations from the Prior (3rd) Edition Not Supported by Evidence Meeting Current Standards Hyperventilation is recommended as a temporizing measure for the reduction of elevated intracranial pressure (ICP) Hyperventilation should be avoided during the first 24 hours after injury If hyperventilation is used monitor oxygen delivery venous oxygen saturation (SjO2) brain tissue O2 partial pressure (BtpO2)
Slide 21-

Ventilation Therapies Recommendations
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Anesthetics, Analgesics, and Sedatives Important for prophylaxis or control of intracranial hypertension and seizures Barbiturates have a long history of being used to control intracranial pressure (ICP) Side effects : hypotension and decreased cardiac output, increased intrapulmonary shunting
Slide 23-

Anesthetics, Analgesics, and Sedatives Recommendations
Slide 24-

Anesthetics, Analgesics, and Sedatives Recommendations
Slide 25-

Anesthetics, Analgesics, and Sedatives Recommendations
Slide 26-

Steroids Steroid use the restoration of altered vascular permeability in brain edema reduction of cerebrospinal fluid production attenuation of free radical production Glucocorticoids benefit for patients with brain tumors when administered in the perioperative period However, studies of severe TBI patients failed to find a benefit The Corticosteroid Randomization After Significant Head Injury Trial (CRASH) trial was designed to provide high- quality evidence on the impact of steroids on TBI patients
Slide 27-

Steroids Recommendations
Slide 28-

Nutrition The complex interaction of the body with nutritional support is magnified during illness, particularly after severe traumatic brain injury (TBI) Seminal work from the 1980s demonstrated that severe TBI was associated with increased energy expenditure early after injury More recent evidence suggests that contemporary neurocritical care may blunt this response, but these studies underscore the complex interactions that are in play simply in determining how many calories should be administered to patients with severe TBI.
Slide 29-

EVALUATION OF THE EVIDENCE
Slide 30-

Nutrition Recommendations
Slide 31-

Infection Prophylaxis Severe traumatic brain injury can increase a patient’s susceptibility to infection The use of mechanical ventilation Invasive monitoring Patients undergoing intracranial pressure (ICP) monitoring have related infection rates as high as 27%
Slide 32-

Infection Prophylaxis For external ventricular drains (EVDs) prophylactic intravenous (IV) antibiotics reduces infection rates or increases the risk of drug-resistant organisms Ventilator associated pneumonias (VAP) may be as high as 40%, and associated with longer exposure to mechanical ventilation The occurrence of VAP represents a significant morbidity
Slide 33-

Infection Prophylaxis Recommendations
Slide 34-

Infection Prophylaxis Recommendations
Slide 35-

Infection Prophylaxis Recommendations
Slide 36-

Deep Vein Thrombosis Prophylaxis 54% incidence of DVT without prophylactic treatment 25% incidence in patients with isolated TBI treated with sequential compression devices
Slide 37-

Deep Vein Thrombosis Prophylaxis Significant risk for VTE due to hypercoagulability resulting from the primary brain injury prolonged periods of immobilization focal motor deficits Non pharmacologic Vs Pharmacologic prevention
Slide 38-

Deep Vein Thrombosis Prophylaxis Recommendation
Slide 39-

Seizure Prophylaxis Post-traumatic seizures (PTS) are classified as Early < 7 days of injury late > 7 days following injury Post-traumatic epilepsy (PTE) is defined as recurrent seizures > 7 days following injury
Slide 40-

Seizure Prophylaxis
Slide 41-

Seizure Prophylaxis
Slide 42-

Seizure Prophylaxis Seizure prophylaxis for PTS refers to the practice of administering anticonvulsants to patients following TBI
Slide 43-

Seizure Prophylaxis Recommendations
Slide 44-

Part II : Mornitoring
Slide 45-

Intracranial pressure monitoring
Slide 46-

Intracranial Pressure Monitoring Recommendations
Slide 47-

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Slide 48-

Cerebral perfusion pressure monitoring CPP = MAP – ICP MAP measured at the level of the heart ICP at the level of the foramina of Monro, or the external auditory meatus
Slide 49-

Cerebral Perfusion Pressure monitoring Recommendations
Slide 50-

Advanced Cerebral Monitoring Brain Tissue Oxygen (PbrO2) Monitoring Transcranial Doppler and Microdialysis Jugular Bulb Monitoring of Arteriovenous Oxygen Content Difference(AVDO2)
Slide 51-

Advanced Cerebral Monitoring Brain Tissue Oxygen (PbrO2) Monitoring
Slide 52-

Brain Tissue Oxygen (PbrO2) Monitoring Recommendations
Slide 53-

Advanced Cerebral Monitoring Transcranial Doppler and Microdialysis Transcranial Doppler uses ultrasound to examine the arteries, measure blood flow, and look for signs of vasospasm. Microdialysis to measure brain metabolism (glucose,lactate, pyruvate, and glutamate) is not common outside of research settings.
Slide 54-

Advanced Cerebral Monitoring Transcranial Doppler
Slide 55-

Transcranial Doppler & Microdialysis Recommendations
Slide 56-

Advanced Cerebral Monitoring Jugular Bulb Monitoring of Arteriovenous oxygen content difference (AVDO2) Measure oxygen saturation of venous blood from brain and calculate Arteriovenous oxygen content difference
Slide 57-

Advanced Cerebral Monitoring
Slide 58-

Part III : Thresholds
Slide 59-

Blood pressure Threshold
Slide 60-

Intracranial Pressure Recommendations
Slide 61-

Intracranial Pressure Recommendations
Slide 62-

Cerebral perfusion pressure (CPP) Recommendations
Slide 63-

Cerebral perfusion pressure (CPP) Recommendations
Slide 64-

Advanced Cerebral Monitoring Thresholds Recommendations
Slide 65-

Take Home Message
Slide 66-

Take home massage
Slide 67-

Take home massage
Slide 68-

Thank you for your attention