TBI

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TBI Overview

1. Primary injury: cell death, DAI, contusion, loss of perfusion, etc
2. Secondary injury: reperfusion, hyperoxia, neurotransmitter release
3. Tertiary injury: delayed apoptosis

Medical Treatment Focus: limit secondary and tertiary injuries

GCS<8: Intubate! or maybe not..

• Most evidence based in EMS / field. Rapid decision situations, not a rule to intubate

TBI brains lose vascular autoregulation - small shifts in CO2 and O2 can drastically change cerebral perfusion pressure. 

ICP Monitoring

Ultrasound: Optic Nerve Sheath >5mm
A Neurointensivist’s Approach to POCUS for Increased ICP — TPA
Ocular Ultrasound Made Easy: Step-By-Step Guide - POCUS 101

CPP = MAP-ICP

2 Measurement methods

1. Parenchymal (Codman) - local measurement, drifts over time (good for ~5 days)
2. Ventricular (EVD) - drains CSF and also measures direct pressure 

EVD Waveform:

Treatment

ICP goal: <20mmHg

Good Supportive Care

• Proper Sedation
• Proper Pain Control
• Head of Bed 30-45 degrees
  Medications
• Hypertonic saline 3% (5mL/kg) or 23.4% (central line only)
• Mannitol (0.5-1.0 mg/kg)
  Craniotomy
• Increases survivability, but much better neuro outcomes in kids
  Hyperventilation (CO2 30-40)
• Short periods only (will reduce overall CPP and lead to anoxia)

Last Ditch Efforts:
Paralysis
Phenobarb Coma

Supportive

• Seizure Prophylaxis
  • Keppra 
  • Versed Drip (50% efficacy of phenobarbital for Seizure prevention, no difference in mortality)
  • Phenobarbital coma (most effective, 30 hour t1/2 prolongs neuro testing)
• Sedation
  • Pick your fave. Beware of Propofol infusion syndrome in kids - <24hrs and low doses are best. 
• Fever
  • TTM normothermia.
• NOT Steroids
  • Only effective in vasogenic edema (tumors, etc)