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Tod Sloan, MD, MBA, PhD University of Colorado at Denver and Health Science Center
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Head Injury
Most common cause of death and disability in young people and children 1.6 million head injuries per year (US) [150,000 pediatric HI] 16% 250,000 admitted to hospital 70,000-90,000 left with permanent neurologic disabilities [ 29,000 children] 32% 52,000-80,000 deaths per year 26% [7,000 children] Severe Approximate mortality 25% Mild Cost of care $1 billion annually
Marik Chest 122:699, 2002
Moderate
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Score: 3 - 15 Severe Head Injury < 8 Moderate Head Injury 9-12 Mild Head Injury 13-15
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Secondary Insults
Hypotension Hyperthermia Hypercapnea Hypocapnea Inflammation Cascade of biomedical events mediated by free radicals, free iron, excitatory neurotransmitters Hypoxia Anemia Hyperglycemia Hypoglycemia Electrolyte Abn. Acid-Base Abn.
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Airway- Breathing
Provide adequate oxygenation avoid hypoxemia inc CBF/ICP Provide adequate ventilation avoid inc PaCO2/CBF/ICP Maintain ETCO2 35-40 mmHg
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Predictors of Outcome
Age CT scan diagnosis Admission GCS score Pupillary reactivity Hypotension
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AB-Circulation
Hypotension is the primary risk factor for poor outcome Most hypotension is due to hemorrhage Systolic BP < 110 mmHg probably need volume resuscitation Systolic < 90 mmHg needs aggressive management. Strategy: euvolemia, normotension, hyperosmolarity Older management strategy of dehydration
No decrease cerebral edema Possibility of hypotension
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Hypoxia
Hypotension
+ Hypoxia
Chestnut J Trauma 34:216, 1993
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Vascular Pathology
Hyperemia leading to increased cerebral blood volume and increased ICP without inducing ischemia Decreased CBF in early hours (loss autoregulation) Vasospasm
Disrupted BBB
68% fatal injuries had ischemia, hyperemia common in non-fatal injuries Fessler, Annals Int Med, 22:998, 1993
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*
1. Reduction global CBF (often to ischemic levels *) autoregulation disrupted, lost at ischemia 2. Supranormal levels 12-24 hours hyperemia metabolism and flow may remain coupled 3. Eventual fall to normal levels and/or vasospasm
Menon Br Med Bull 55:226, 1999
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Low CBF
Vasospasm, Raise lower limit of autoregulation, Direct injury
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CBF
Cerebral ischemia dominates HI as the single most important event determining outcome Hyperventilation could cause further ischemia
Lewelt J Neurosurg 53:500, 1980
In some HI, low CBF is normal (i.e. associated with normal oxygen extraction (matched metabolism)
Obrist J Neurosurg 61:241, 1984
In some HI, increases in flow are associated with luxury perfusion with a propensity for edema correctable with hyperventilation Hyperventilation could improve outcome
Cruz Crit Care Med 21:1225, 1993
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Ventilatory Dysrhythmias
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Elevated ICP
Most significant cause of morbidity and mortality with head trauma Miller J Neurosurg 47:503, 1977 Acute elevations may be associated with seizures ICP > 25 mmHg use barbiturates (may control up to 25% of patients Ingvar, Cerebral Function and Metabolism, Copenhagen 1977, p 156
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Craniotomy
30-50% of HI patients benefit from craniotomy Acute subdural 90% mortality if evacuated > 4 hours 30% mortality if evacuated < 4 hours
Seeling NEJM 304:1511, 1981
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ICP Management
Lower Brain Bulk: 800-1000 cc
Mannitol, lasix, hypertonic saline steroids (tumors)
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Mannitol
Osmotic dehydration of the Brain Reduces blood viscosity and expands vascular volume - increasing CBF resulting in vasoconstriction and dec CBV/ICP May cause dehydration, hypotension and pre-renal azotemia Opens blood-brain barrier cause reverse osmotic shift
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Hypertonic Saline
Increase blood pressure
Bring volume from tissues into circulation
Lower ICP
Cause osmotic cerebral dehydration
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Hypothermia
Shown to be protective during ischemia in numerous animal studies In man, no improvement with HI and worsens infarct during ischemia
Clifton NEJM 344:556, 2001, Dietrich J Neurotrauma, 9 Suppl:475, 1992
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Management Alternatives
Reduce ICP
Lower ICP < 20 mm Hg
Improve CPP
Raise CPP (60-70 mmHg)to improve CBF
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Cerebral Management I
Traditional Therapy ICP focused Pathophysiology: Control ICP
Barbiturate Coma Hyperventilation Osmotherapy Neuromuscular Block CSF Drainage
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Cerebral Management II
Rosner - Adjust CPP Pathophysiology vasodilatory cascade lowered CPP because dec BP or inc ICP cause vasodilation Rx raise BP break cycle CPP - > 70-80 mmHg, above lower limit autoregulation to keep CBF normal
Rosner J Neurosurg 83:949, 1995
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Cerebral Management IV
Individualized Therapy Management is directed at the specific pathophysiology Vascular causes hypnotic-sedative agents Edema osmotic agents CPP- treat as necessary
Miller Acta Neurochir Suppl (Wien) 57:152, 1993
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Anesthesia and HI
Inhalational Agents
Decrease metabolism Change metabolic coupling
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Anesthesia and HI
Intravenous Agents Decrease metabolism Maintain metabolic coupling Desirable Impact Decrease CBF/ICP Effect limited at full synaptic depression May have hemodynamic impact at higher doses Opioid effect appears related to vasodilation from decreased BP and autoregulation
Ketamine is an exception as it increases CBF/ICP and is undesirable
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Field Guidelines
All reasonable efforts should be made to avoid hypoxemia and hypotension
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