Evidenced-Based

Care of Traumatic
Head Injured Patients

Nyoman Golden
Objectives

• Discuss the scientific rationale for the therapeutic

interventions used in the care of brain injury

• Provide research based recommendations for the care

traumatic brain injury
 Monroe- Kellie Principle

Copied from: Rogers (1996) Textbook of Pediatric Intensive Care

p. 646
 Traumatic Mass Occupying Lesions

• Epidural hematoma

• Subdural hematoma

• Subarachnoid hemorrhage

• Intra-paranchymal hemorrhage
 Cerebral Spinal Fluid

• Produced by the choroid plexus

• Average volume 90 - 150 ml
– (0.35 ml / minute or 500 ml / day)
• Reabsorbed through the arachnoid villi
• Drainage may be blocked by inflammation of the
arachnoid villi, diffuse cerebral edema, mass effect of
hemorrhage or intraventricular hemorrhage
 Cerebral Blood Flow
Regulation of Cerebral Vascular Resistance

CBF

Normal
50 - 100
ml / min

MAP PaCo2
(mmHg) (mmHg)
Normal 60 - 150 mmHg Normal 30 - 50 mmHg

Adapted from: Rogers (1996) Textbook of Pediatric Intensive Care

pp. 648 - 651
 Cerebral Edema

• Cellular response to injury

– Primary injury (mechanical trauma at time of event) and ...
• Secondary injury
– Hypoxic-ischemic injury
• Injured neurons have increased metabolic needs
• Concurrent hypotension and hypoxemia may be
present
• Inflammatory response results
 Diffuse Axonal Injury
• Shearing injury of axons
• Deep cerebral cortex, thalamus, basal ganglia
• Punctate hemorrhage and diffuse cerebral edema

Image from: Neuroscience for Kids

www.faculty.washington.edu/chudler/cells/html
 Neuronal Response to Injury
Primary mechanical injury & secondary hypoxic-ischemic injury

Inflammation:
ATP Lactate Ca+ Vasoreactivity
Thrombosis
Glucose Acidosis Neutrophils
NMDA
O .
Edema Glutamate
Cyclooxygenase
Lipoxygenase
Arachidonic Acid
Leukotriene
Thromboxane
Prostaglandin Fluid
T.Trimarchi 2000
 Is hyperglycemia detrimental?
• Hyperglycemia is associated with high brain lactate levels and possibly
greater cerebral cellular injury, particularly in the early phases of brain
injury (animal research / not conclusive / older studies)
– Recommendation: Avoid hyperglycemia, particularly during the
early stages of brain injury. Consider the use of intravenous
solutions that do not contain dextrose for early fluid and electrolyte
management
Chopp et al., (1988). Stroke, 19.
Lanier et al., (1987). Anesthesiology, 66.
Ljunggren et al. (1974). Brain Research, 77.
Myers et al., (1976). Journal of Neuropathology and Experiemental Neurology, 35.
Smith et al. (1986). Journal of Cerebral Blood Flow and Metabolism, 6.
Natale et al. (1990). Resuscitation, 19.

Source: Rogers (1996) Textbook of Pediatric Intensive Care pp.702-704

 Monitoring Brain Metabolism

• Jugular Venous Catheter

• Jugular Venous Oxygen Saturation (SJVO2)
• Arteriojugular Venous Oxygen Difference (AJVO2)
• Cerebral Metabolic Rate For Oxygen (CMRO2)
Possible better outcome when used (adult study)
Cruz (1998) Critical Care Medicine, 26(2)
• Brain Sensors
• Brain tissue pH, PaO2, PcO2, lactate
Kiening (1997) Neurology Research, 19(3)
 Basic Monitoring Ong et al. (1996) Pediatric
Neurosurgery, 24(6)
• Serial neurologic examinations
GCS, hypoxemia and
• Circulation / respiration radiologic evidence of SAH,
• Intracranial Pressure cerebral edema and DAI are
predictive of morbidity
• Cerebral Perfusion Pressure
• Radiologic Studies GCS alone does not predict
morbidity
• Laboratory Studies
=
Scherer & Spangenberg,
(1998) Critical Care
Medicine, 26(1)
Fibrinogen and
platelets are
significantly
decreased in TBI
patients
Overview:
Management of Traumatic Head Injury

• Maximize oxygenation and ventilation

• Support circulation / maximize cerebral perfusion

pressure

• Decrease intracranial pressure

• Decrease cerebral metabolic rate

 Respiratory Support: Maximize Oxygenation
• Hypoxemia is predictive of morbidity
– Ong et al. (1996) Pediatric Neurosurgery, 24(6)
• Neurogenic pulmonary edema, concurrent lung injury, development
of ARDS may be present
– Is use of Positive End Expiratory Pressure to maximize
oxygenation a safe practice?
• May impair cerebral venous return
– Cooper et al. (1985) Journal of Neurosurgery, 63
• PEEP > 10 cm H2O increases ICP
– Feldman et al. (1997) Journal of Neurosurgical
Anesthesiology, 9(2)
 Respiratory Support: Normoventilation
Hyperventilation : Historical management more harm than good ???
CBF pre- hyperventilation CBF post-hyperventilation

Originally
adapted from
research by
Skippen et al.
(1997) Critical
Care Medicine,
25

Image from: ALL-NET Pediatric Critical Care Textbook

www.med.ub.es/All-Net/english/neuropage/protect/vent-5htm
 Research Supporting Normoventilation

• Forbes et al. (1998) Journal of Neurosurgery, 88(3)

• Marion et al. (1995) New Horizons, 3(3)

• McLaughlin & Marion (1996) Journal of Neurosurgery, 85(5)

• Muizelaar et al. (1991) Journal of Neurosurgery, 75(5)

• Newell et al. (1996) Neurosurgery, 39(1)

• Skippen et al. (1997) Critical Care Medicine, 25(8)

• Yundt & Diringer (1997) Critical Care Clinics, 13(1)

Use of Hyperventilation ...

• Transient management of very acute and serious elevation of

intracranial pressure
• Possible role for occassional, preemptive use before activities
known to seriously increase intracranial pressure
• No lower than 32-35 cmH20

--- Moderate and transient ---

 CPP = MAP - ICP
Circulatory Support:
Maintain Cerebral Perfusion Pressure

5
Number of 4 Good
Hypotensive Moderate
Episodes in 3
the first 24 Severe
hours after 2 Vegetative
TBI Dead
1

0
Patient Outcome

Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

 CPP = MAP - ICP
Circulatory Support:
Maintain Cerebral Perfusion Pressure

• Adelson et al. (1997) Pediatric Neurosurgery, 26(4)

– Children (particularly < 24 months old) are at increased
risk of cerebral hypo-perfusion after TBI
– Low CBF is predictive of morbidity

• Rosner et al. (1995) Journal of Neurosurgery, 83(6)

– Management aimed at maintaining CPP (70 mmHg)
improves outcomes
Decreasing Intracranial
Pressure Brain Blood

CSF Mass
• Evacuate hematoma Bone
• Drain CSF
– Intraventricular catheters use is limited by degree of
edema and ventricular effacement
• Craniotomy
– Permanence, risk of infection, questionable benefit
• Reduce cerebral edema
• Promote venous return
• Reduce activity associated with elevated ICP

• Reduce cerebral metabolic rate

 Decreasing Intracranial Pressure:
Hyperosmolar Therapy: Increase Blood Osmolarity

Brain Blood
cell vessel
Fluid

Movement of
fluid out of cell
reduces edema

Osmosis: Fluid will move from area of lower osmolarity to an

area of higher osmolarity

T. Trimarchi, 2000
 Decreasing Intracranial Pressure:
Diuretic Therapy
Osmotic Diuretic Loop Diuretic
• Mannitol (0.25-1 gm / kg) • Furosemide
• Increases serum osmolarity • Decreased CSF formation
• Vasoconstriction (adenosine) / • Decreased systemic and
less effect if autoregulation is cerebral blood volume
impaired and if CPP is < 70 (impairs sodium and water
• Initial increase in blood movement across blood brain
volume, BP and ICP followed barrier)
by decrease • May have best affect in
• Questionable mechanism of conjunction with mannitol
lowering ICP – Pollay et al. (1983)
– Rosner et al. (1987) Journal of Neurosurgery,
Neurosurgery, 21(2) 59 ; Wilkinson (1983)
Neurosurgery,12(4)
 Decreasing Intracranial Pressure:
Hypertonic Fluid Administration
• Fisher et al. (1992) Journal of Neurosurgical Anesthesiology, 4
– Reduction in mean ICP in children 2 hours after bolus
administration of 3% saline

• Taylor et al. (1996) Journal of Pediatric Surgery,31(1)

– ICP is lowered by resuscitation with hypertonic saline vs.
lactated ringers solution in an animal model

• Qureshi et al. (1998) Critical Care Medicine, 26(3)

– Reduction in mean ICP within 12 hours of continuous
infusion of 3% sadium acetate solution
– Little continued benefit after 72 hours of treatment
 Hyperosmolar Therapy

Goal:
Sodium 145-155
mmol/L

• Sodium: square
• ICP: circle

Copied from: Qureshi et al. (1998) Critical Care Medicine, 26(3)

 Decrease Intracranial Pressure: Promote Venous Drainage
Keep neck mid-line and elevate head of bed …. To what degree?
Feldman et al.
(1992) Journal of
Neurosurgery, 76
March et al.
(1990) Journal of
Neuroscience
Nursing, 22(6)
Parsons & Wilson
(1984) Nursing
Research, 33(2)

Image from: Dicarlo in ALL-NET Pediatric Critical Care Textbook

www.med.ub.es/All-Net/english/neuropage/protect/icp-tx-3.htm
 Decrease Intracranial Pressure:
Problems:
Management of Pain & Agitation
• Difficult to
• Opiods
assess neurologic
• Benzodiazepines exam
• Risk of
Management of Movement hypotension
• Neuromuscular blockade may be Use short
required - use only when necessary acting agents

Do opiods increase CBF and ICP as well as lower MAP and CPP?
Increased ICP with concurrent decreased MAP and CPP has been
documented with use of opiods. But, elevation in ICP is transient and
there is no resulting ischemia from decreased MAP / CPP.
Albanese et al. (1999) Critical Care Medicine, 27(2)
 Nursing Activities and ICP
20
18
16
14
12
ICP Turning
10
8
Suctioning
6 Bathing
4
2
0
Before During After

Rising (1993) Journal of Neuroscience Nursing, 25(5)

 Suctioning Practices
• Hyper-oxygenation 53% Percent increase in
• Mild / moderate hyperventilation
ICP with
– Brown & Peeples (1992) Heart & suctioning using
Lung, 21
preemptive
– Parsons & Shogan (1982) Heart & hyperventilation,
Lung, 13 IV lidocaine and IT
• Intratracheal / intravenous lidocaine lidocaine
– Donegan & Bedford (1980)
0%
Anesthesiology, 52
– Wainright & Gould (1996) Hypervent
Intensive & Critical Care Nursing, IV lido
12 IT lido
Individualize suctioning practices Wainright & Gould (1996)
according the patient’s response
 Family Contact and ICP
Presence, touch and voice of family / significant others...
• Does not significantly increase ICP
• Has been demonstrated to decrease ICP
Bruya (1981) Journal of Neuroscience Nursing, 13
Hendrickson (1987) Journal of Neuroscience Nursing,
19(1)
Mitchell (1985) Nursing Administration Quarterly, 9(4)
Treolar (1991) Journal of Neuroscience Nursing, 23(5)

Note: Visitors require education and

preparation before spending time at bedside !
 Reduction of Cerebral Metabolic Rate
• Goal: Reduce cerebral oxygen requirement
– Anticonvulsants
• To prevent seizure activity
– Pentobarbital ??
• Adverse effects include hypotension and bone marrow
dysfunction
• Used only after unsuccessful attempts to control ICP and
maximize CPP with other therapies
• Improved outcome not fully supported by research

Traeger et al. (1983) Critical Care Medicine, 11

Ward et al. (1985) Journal of Neurosurgery, 62(3)
 Reduction of Cerebral Metabolic Rate: Hypothermia
• Metz et al. (1996) Journal of Neurosurgery, 85(4)
– 32.5 C reduced cerebral metabolic rate for oxygen (CMRO2) by
45% without change in CBF
– intracranial pressure decreased significantly (p < 0.01)
• Marion et al. (1997) New England Journal of Medicine, 336(8)
– At 12 months, 62% of patients (GCS of 5-7) cooled to 32-33 C
have good outcomes vs. 38% of patients in control group
Side-effects:
• Potassium flux Requires: No
• Coagulopathy • Slow re-warming pediatric
• Shivering • Close monitoring studies!
• Skin Breakdown
Summary of Recommended Practices

• Serial neurologic assessments and physical examination

• Continuous cardio-respiratory, ICP, and CPP monitoring, +/-
cerebral metabolism monitoring adjuncts
• Maximize Oxygenation and Ventilation
– Maximize oxygenation (cautious use of PEEP / keep PEEP < 10 to
prevent inhibited venous return / individualize according to patient
response)
– Normoventilate
– Support circulation / maximize cerebral perfusion pressure
– Maintain mean arterial blood pressure and maintain CPP (goal > 60)
Summary of Recommended Practices
• Decrease intracranial pressure
– Evacuate mass occupying hemorrhages
– Consider draining CSF with ventriculostomy when possible
– Hyperosmolar therapy, +/- diuresis (cautious use to avoid
hypovolemia and decreased BP)
– Mid-line neck, elevated head of bead (some research supports
elevation not > 30 degrees)
– Treat pain and agitation - consider pre-medication for nursing
activities, +/- neuromuscular blockade (only when needed)
– Careful monitoring of ICP during nursing care, cluster nursing
activities and limit handling when possible
– Suction only as needed, limit passes, pre-oxygenate / +/- pre-
hyperventilate (PaCo2 not < 30) / use lidocaine IV or IT when
possible
– After careful preparation of visitors, allow calm contact
Summary of Recommended Practices
• Decrease Cerebral Metabolic Rate
– Prevent seizures
– Reserve pentobarbital for refractory conditions
– Avoid hyperthermia, +/- hypothermia
– Avoid hyperglycemia (early)