Guidelines for the Management of Severe Traumatic Brain

Guidelines for the Management of Severe Traumatic Brain A joint initiative of: Injury The Brain Trauma Foundation The American Association of Neurological Surgeons The Joint Section on Neurotrauma and Critical Care 1

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TBI - Epidemiology • 60, 000 ANNUAL TOTAL TBI DEATHS* • 44, 000 OCCUR AT SCENE OR IN E. R. • 16, 000 OCCUR AFTERWARDS Challenge is to reduce mortality and improve outcome. *lower limit estimate Sosin et al. JAMA 1995, 273: 1778 -1780 3

Secondary Injury • In the past two decades, medical research has demonstrated that all brain damage does not occur at the moment of impact, but evolves over the ensuing hours and days. This is referred to as secondary injury. • The injured brain is extremely vulnerable to hypotension, hypoxia, and increased intracranial pressure which are causes of secondary injury. 4

Survey of 219 hospital intensive care units in 45 states that treated patients with severe head injury. Centers % Routine ICP monitoring (more in high volume centers) 28 Hyperventilation and osmotic diuretics routinely used 83 Aiming for Pa. CO 2 < 25 mm Hg 29 Corticosteroids use more than half the time 64 Crit Care Med 23: 560 -567, 1995 5

Findings • ICP monitoring used infrequently • Severe hyperventilation • Use of steroids currently not indicated • Wide variability in practice 6

Significant Reductions in Mortality and Morbidity • Rapid transport to a trauma care facility • Prompt resuscitation • CT scanning • Prompt evacuation of significant intracranial hematomas • ICP monitoring and treatment 7

Guidelines for Management of Severe TBI Objectives: • STATE and DISSEMINATE the current scientific evidence for the OPTIMAL management of TBI. • Highlight issues for further RESEARCH and CLINICAL TRIALS. • Improve OUTCOME. 8

Guidelines for the Management of Severe Traumatic Brain Injury Authors Ross Bullock Raj Narayan Randall Chesnut David Newell Guy Clifton Lawrence Pitts Jamshid Ghajar Michael Rosner Donald Marion Beverly Walters Jack Wilberger 9

History • 11 authors and 14 topics • 3 years of meetings • Over 3000 articles reviewed • 1 st edition completed in 1995 • 2 nd edition completed in 1999 Funded and supported by the Brain Trauma Foundation (BTF) 10

Advisory Committee • Mark Dearden, M. D. • Robert Florin, M. D. • Andrew Jagoda, M. D. • James P. Kelly, M. D. • Andrew Maas, M. D. • Anthony Marmarou, Ph. D. • J. Douglas Miller, M. D. 11

Advisory Committee • Peter C. Quinn • Jay Rosenberg, M. D. • Franco Servadei, M. D. • Nino Stocchetti, M. D. • Graham Teasdale, M. D. • Andreas Unterberg, M. D. • Hans von Holst, M. D. • Alex Valadka, M. D. 12

Topics • Trauma Systems • Initial Management • Resuscitation of Blood Pressure and Oxygenation • Indications for ICP Monitoring • ICP Treatment Threshold • ICP Monitoring Technology • Cerebral Perfusion Pressure 13

Topics • Hyperventilation • Mannitol • Barbiturates • Steroids • ICP Treatment Algorithm • Nutrition • Antiseizure Prophalyxis 14

Topic Chapter Format I. Recommendations A. Standards B. Guidelines C. Options II. Overview III. Process IV. Scientific Foundation V. Summary VI. Key Issues for Future Investigation VII. Evidentiary Table VIII. References 15

Guidelines for the Management of Severe Traumatic Brain Injury Topics list • Electronic literature search (Medline) • All relevant articles: – Screened for scientific and statistical validity – Classified according to a three point scale • Class III 16

Guidelines for the Management of Severe Traumatic Brain Injury Class I • Prospective, Randomized, Controlled Trials Class II • Non-Randomized, Prospective Controlled Trials • Observational Studies Class III • Case Series • Case Reports • Expert Opinion 17

Guidelines for the Management of Severe Traumatic Brain Injury Standards • Class I Evidence Guidelines • Class II Evidence Options • Class III Evidence 18

Guidelines for the Management of Severe Traumatic Brain Injury Standards • Represent principles that reflect a high degree of clinical certainty Guidelines • Represent principles that reflect a moderate degree of clinical certainty Options • Represent principles for which there is unclear clinical certainty 19

Guidelines for the Management of Severe Traumatic Brain Injury “The Spirit is Willing but the Data is Weak” • State only what the literature supports – First step toward standardizing head injury management – Mandate for Class I studies 20

Trauma Systems Guideline • All regions in the United States should have an organized trauma care system 21

• 1643 trauma patients treated at seven trauma centers with differing annual volumes of trauma patients. • Patients taken to a low volume trauma center had a 30% greater chance of dying. J. Trauma 30: 1066 -1076, 1990 22

Resuscitation of Blood Pressure & Oxygenation Guideline • Hypotension (SBP < 90 mm Hg) or hypoxia (apnea of cyanosis in the field or a Pa. O 2 < 60 mm Hg) must be scrupulously avoided, if possible, or corrected immediately. Option • The mean arterial pressure should be maintained above 90 mm Hg throughout the patient’s course. 23

• Prospective prehospital and E. R. study of 717 severe head injury patients in the Traumatic Coma Data Bank. • Hypotension (SBP < 90 mm Hg) occurred in 35% of patients and was associated with a two fold increase in mortality. J. Trauma 34: 216 -222, 1993 24

Initial Management Option • The first priority for the head injured patient is complete and rapid physiologic resuscitation. No specific treatment should be directed at intracranial hypertension in the absence of signs of transtentorial herniation or progressive neurologic deterioration not attributable to extracranial explanations. 25

• CBF measured in 35 severely head injured patients with Xe-CT at, on average, 3 hours after injury. • Global or regional ischemia (CBF < 18 ml/100 gm/min) observed in 31% patients. • Global ischemia was measured in 57% of patients with diffuse swelling. J. Neurosurg 77: 360 -368, 1992 26

Indications for ICP Monitoring Guideline • ICP monitoring is appropriate in severe head injury patients with an abnormal CT, or a normal CT scan if 2 or more of the following are noted on admission: – SBP < 90 mm Hg – Age > 40 years – Uni-/Bilateral motor posturing 27

• 207 severely head injured patients who had ICP monitoring and head CT scans • Patients with a normal head CT had a 13% chance of ICP > 20 mm Hg • Risk of intracranial hypertension (with normal CT) increased to 60% if two or more of the following were noted: – 1) Age over 40 years – 2) SBP < 90 mm Hg – 3) motor posturing J. Neurosurg 56: 650 -659, 1982 28

ICP Monitoring Technology Recommendation • In the current state of technology, the ventricular catheter connected to an external strain gauge is the most accurate, low cost, and reliable method of monitoring ICP. It also allows therapeutic CSF drainage. • ICP transduction via fiberoptic or strain gauge devices placed in ventricular catheters provide similar benefits but at a higher cost. 29

CT Scan 30

ICP Treatment Threshold Guideline • ICP treatment should be initiated at an upper threshold of 20 - 25 mm Hg. 31

• The ICP threshold that was most predictive of 6 month outcome was analyzed in 428 severely head injured patients. • The proportion of hourly ICP reading greater than 20 mm Hg was a significant independent determinant of outcome. J. Neurosurg 75: S 59 -S 66, 1991 32

Cerebral Perfusion Pressure Option • Cerebral Perfusion Pressure should be maintained at a minimum of 70 mm Hg. 33

• 158 patients with GCS < 7 managed according to a CPP protocol: – Maintain euvolemia (CVP 8 -10 mm Hg) – Ventriculostomy CSF drainage at 15 mm Hg – Systemic vasopressors to maintain CPP at least 70 mm Hg – Hyperventilation, barbiturates, hypothermia not used. • Mortality 29% and 2% vegetative for entire group. Favorable outcome in GCS 3 of 35% ranging up to 75% for GCS 7. J. Neurosurg 83: 949 -962, 1992 34

Hyperventilation Standard • In the absence of increased intracranial pressure (ICP), chronic prolonged hyperventilation therapy (Pa. CO 2 of 25 mm Hg or less) should be avoided after severe traumatic brain injury (TBI). Guideline • The use of prophylactic hyperventilation (Pa. CO 2 < 35 mm Hg) therapy during the first 24 hours after severe TBI should be avoided because it can compromise cerebral perfusion during a time when cerebral blood flow (CBF) is reduced. Option • Hyperventilation therapy may be necessary for brief periods when there is acute neurologic deterioration, or for longer periods if there is intracranial hypertension refractory to sedation, paralysis, cerebrospinal fluid (CSF) drainage, and osmotic diuretics. 35

• A randomized prospective clinical trial in 113 patients to study the effect of hyperventilation (Pa. Co 2 25 mm Hg) compared to normal ventilation (Pa. Co 2 35 mm Hg) in patients with similar severe head injury. • Significantly fewer patients made a good recovery at 3 and 6 months post injury who had a GCS 6 or 7 on admission. “PROPHYLACTIC USE OF SUSTAINED HYPERVENTILATION FOR A PERIOD OF 5 DAYS RETARDS RECOVERY FROM SEVERE HEAD INJURY. ” J. Neurosurg 75: 731 -739, 1991 36

Mannitol Guideline • Mannitol is effective for control of raised ICP after severe head injury. Option • Effective doses range from 0. 25 - 1. 0 gm/kg body weight. 37

Mannitol Option • The indications for the use of mannitol prior to ICP monitoring are signs of transtentorial herniation or progressive neurological deterioration not attributable to systemic pathology. • However, hypovolemia should be avoided by fluid replacement. 38

Barbiturates Guideline • High-dose barbiturate therapy may be considered in hemodynamically stable salvagable severe head injury patients with intracranial hypertension refractory to maximal medical and surgical ICP lowering therapy. 39

• A prospective trial of 73 patients with severe head injury and medically refractory intracranial hypertension, randomized to receive either a regimen including high-dose pentobarbital or similar regiment without pentobarbital. • Refractory intracranial hypertension occurred in only 12% of the original severe head injury group (925 Patients). • The chance of survival for those patients whose ICP decreased(ICP < 20 mm Hg) with barbiturate treatment was 92% compared to 17% when it did not. J. Neurosurg 69: 15 -23, 1988 40

Steroids Standard • The use of steroids is not recommended for improving outcome or reducing intracranial pressure in patients with severe head injury. 41

• Prospective randomized trial in 300 patients receiving dexamethasone (total IV dose within 51 hours of injury = 2. 3 grams IV) versus placebo. • No difference in outcome examined serially within one year after treatment. Zentralbl Neurochir 55: 135 -143, 1994 42

Antiseizure Prophylaxis Standard • Prophylactic use of phenytoin, carbamazepine, phenobarbital or valproate is not recommended for preventing late post-traumatic seizures. 43

• 404 post traumatic head injury patients (GCS 3 -10 and abnormal head CT) randomized to treatment with phenytoin or placebo for one year with a two year follow up. • In the first week after injury 4% of the patients receiving phenytoin had seizures compared to 14% taking placebo. • After the first week there was no significant difference between the rate of seizures in the two groups. N. Engl. J. Med 323: 497 -502, 1990 44

Nutrition Guideline • Replacement of 140% of Resting Metabolic Expenditure in non-paralyzed patients and 100% Resting Metabolic Expenditure in paralyzed patients using enteral or parenteral formulas containing at least 15% of calories as protein by the seventh day after injury. 45

• Prospective trial in 38 patients randomly assigned to receive total parenteral nutrition (TPN) or standard enteral nutrition (SEN). • The TPN group got full nutritional support by 7 days whereas the SEN group did not. There were significantly more deaths in the group that did not receive full caloric replacement by the 7 th day after injury. J. Neurosurg 58: 907 -912, 1983 46

ICP Treatment Algorithm Option • An algorithm, developed by consensus, is presented. It should be viewed as “expert opinion” and used as a framework which may be useful in guiding an approach to treating intracranial hypertension. 47

Critical Pathway for Treatment of Intracranial Hypertension in the Severe Head Injury Patient (Treatment Option) Insert ICP Monitor Maintain CPP 70 mm. Hg YES NO Intracranial Hypertension? * Ventricular Drainage (if available) YES Consider Repeating CT Scan Intracranial Hypertension? NO May Repeat Mannitol if Serum Osmolarity < 320 m. Osm/L & Pt euvolemic Mannitol (0. 25 - 1. 0 g/kg IV) YES Intracranial Hypertension? Carefully Withdraw ICP Treatment NO Hyperventilation to Pa. CO 2 30 - 35 mm. Hg YES Other Second Tier Therapies Intracranial Hypertension? High Dose Barbiturate therapy NO • Hyperventilation to Pa. CO 2 < 30 mm. Hg • Monitoring Sj. O 2, AVDO 2, and/or. CBF Recommended Second Tier Therapy 48 *Threshold of 20 -25 mm. Hg may be used. Other values may be substituted in individual conditions.

Guidelines for the Management of Severe Traumatic Brain To place an order call: Injury Brain Trauma Foundation @ 1 -212 -772 -0608 fax 1 -212 -772 -0357 www. braintrauma. org 49

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