Neurocritical Transfers NE NC London Critical Care Network

Neuro-critical Transfers NE NC London Critical Care Network

Case summary • 65 year old brought to ED after a fall while coming out of pub. – Confused and agitated. – Contusion over right temporal region – Smelling of alcohol

• What will you do? • What is your immediate concern? • How will you manage this case?

Anatomy & relevance of secondary brain injury • Prevention of secondary brain injury – Why this is important? • Cerebral perfusion pressure – Why it is important to maintain it?

Severity of brain injury • GCS Score- what are the components? –E –V –M • Severity of brain injury based on GCS – Mild ? GCS – Moderate – Severe

Indication for CT Scan ● High Risk Patient ● GCS score still < 15 two hours after injury ● Neurologic deficit ● Open skull fracture ● Sign of basal skull fracture ● Extremes of age

Indication for CT Scan ● Moderate risk patients ● ● “Dangerous mechanism” Retrograde amnesia > 30 minutes in duration Severe headache Vomiting > 2 episodes • GCS < 13 • Warfarin or bleeding disorder • Different rule for non-trauma and Age < 16 year

Difference between extradural and subdural • Diffuse injury Vs localised • Subdural Vs Extradural • Midline shift?

Management priorities • ABCDE • Prevention of Secondary brain injury – Adequate oxygenation – Adequate ventilation – Adequate blood pressure • Focussed neurological exam – GCS – Pupil – Lateralising signs

After Initial management • Transfer of image & Referral to neurosurgical centre • Time critical Transfer

Airway • Indications for intubation – Low GCS <9 – Rapidly falling GCS >2 points – Control of Pa. O 2 & Pa. CO 2 – Significant oral / Max Fax bleeding • Secured with ET tube • RSI induction • NG insertion

Urgent Neurosurgery • • • ASDH EDH Posterior fossa bleed Acute hydrocephalus SAH with deteriorating GCS

Referral to Specialist Neurosurgical Centre…. • Time critical transfer • What needs to be done before transfer takes place? • Primary vs secondary brain injury

Breathing • • • Mechanical ventilation Pa. O >11 k. Pa Pa. CO 2 4. 5 -5. 0 Arterial blood gas Et. CO 2

Circulation • • • 2 x large bore cannula IABP Fluid resuscitation Central line access (but not to cause delay) Ensure good jugular venous drainage MAP >80 mm. Hg (CPP >60 mm. Hg) • CPP = MAP - ICP

Disability • • Reduce Cerebral Metabolic O 2 requirements Sedation / Paralysis Treat seizures (Phenytoin 15 mg/kg) Pupils Hyperosmolar therapy (1 -1. 4 g/Kg 20% Mannitol) Na <155 Posm <320 BM 6 -10

Exposure • Normothermia • Catheterise …. . AND EVERYTHING ELSE!

A Systematic Approach Assessment of the patient • Airway & Cervical spine • Breathing -Pa. O 2, Et. CO 2, ventilator & suction • Circulation - lines, “uppers”, monitoring • Disability - sedation, paralysis, neuro protection • Exposure - Blankets, other injuries • Fluids – crystallloid, hypertonics, blood, electrolytes, catheterise • Gut - ? NG, antiemetics • Haematology – FBC/U&Es/Clotting/G&S • Imaging & Notes • Journal - transfer documents Organisational • Kit – transfer bag, pumps, power cables, monitor • Location (phone numbers / contact) • Money • Nourishment • Outdoor protection • Phone • Ready to ….