Head InjuryHead Injury

Practical Aspects of Practical Aspects of Management and Management and

Transfer.Transfer.

Susanne YoungSusanne Young

CONTENTCONTENT

Head Injuries Background Head Injuries Background INITIAL MANAGEMENTINITIAL MANAGEMENT Current Guidelines- ATLSCurrent Guidelines- ATLS Prevention of secondary Brain Injury (1-4)Prevention of secondary Brain Injury (1-4) Use of adjunct therapiesUse of adjunct therapies TRANSFERTRANSFER Which Sedative?Which Sedative? AAGBIAAGBI

BACKGROUNDBACKGROUND

Head injury accounts for approximately Head injury accounts for approximately 300 per 100 000 hospital admissions 300 per 100 000 hospital admissions per year; of these, 9 per 100 000 die.per year; of these, 9 per 100 000 die.

RTA's account for about 25% of cases RTA's account for about 25% of cases and about 60% of deaths; many die and about 60% of deaths; many die before reaching hospital. before reaching hospital.

The aim of management is to minimise The aim of management is to minimise damage arising from secondary damage arising from secondary complications.complications.

PROGNOSISPROGNOSIS

Traumatic Brain Injury- prognosis Traumatic Brain Injury- prognosis at 48HRSat 48HRS

GCS <8- severeGCS <8- severe

9-12- moderate9-12- moderate

13-15- mild13-15- mild

INITIAL MANAGEMENTINITIAL MANAGEMENT

A-A-secure a clear airway and control secure a clear airway and control cervical spine cervical spine

B-B-treat hypoventilation, severe treat hypoventilation, severe chest injury chest injury

C-C-control haemorhage and treat control haemorhage and treat shock shock

D-D-assessassess disability disability E-exposure,E-exposure, prevent hypothermia prevent hypothermia * *

Principles of managementPrinciples of management

Prevention of secondary cerebral Prevention of secondary cerebral injury:injury:

1 Hypoxia1 Hypoxia 2 ICP2 ICP 3 CPP and CBF3 CPP and CBF 4 Cerebral metabolism4 Cerebral metabolism

1 HYPOXIA1 HYPOXIA

PO2 <10kPa for any reasonPO2 <10kPa for any reason If hard collar Consider:If hard collar Consider: 2 person Manual in-line 2 person Manual in-line

immobilisationimmobilisation 33rdrd person cricoid person cricoid Use of McCoy bladeUse of McCoy blade ?Blind Nasotracheal intubation –exc if ?Blind Nasotracheal intubation –exc if

Basal skull #- if skilledBasal skull #- if skilled

2 Control of ICP2 Control of ICP

Signs of raised ICP (>20mmHg)Signs of raised ICP (>20mmHg)

Papilloedema, BP , HR ,fixed pupils, Papilloedema, BP , HR ,fixed pupils, flaccid, irreg resps (brainstem flaccid, irreg resps (brainstem involvement)involvement)

?Hypoventilate- if in doubt DON’T?Hypoventilate- if in doubt DON’T

Moderate hypocapnia CO2 3.5-4 OKModerate hypocapnia CO2 3.5-4 OK

Consider if GCS drops suddenlyConsider if GCS drops suddenly

Very low CO2 –vasoconstriction Very low CO2 –vasoconstriction ischaemiaischaemia

Control of ICP (contd).Control of ICP (contd).

Fluid balance- overload can exacerbate Fluid balance- overload can exacerbate cerebral and pulmonary oedemacerebral and pulmonary oedema

Sedate initially- Sedate initially-

Propofol first linePropofol first line

Add Midaz if ineffectiveAdd Midaz if ineffective

? Thio- may cause haemodynamic ? Thio- may cause haemodynamic disturbance disturbance

? Mannitol 0.25-1g/kg (100ml 20%).? Mannitol 0.25-1g/kg (100ml 20%).

Buys time only, nephrotoxic- watch uo.Buys time only, nephrotoxic- watch uo.

3 Control of CPP and CBF3 Control of CPP and CBF

CPP= MAP- ICP mmHgCPP= MAP- ICP mmHg Min CPP 60/70 for adequate perfusionMin CPP 60/70 for adequate perfusion Cushing reflex designed to restore CPP Cushing reflex designed to restore CPP

in presence of ICP thereforein presence of ICP therefore Don’t treat Hypertension!Don’t treat Hypertension! Mainstay of treatment is to keep Mainstay of treatment is to keep

SBP>90SBP>90 Steroids ineffective (palliative care Steroids ineffective (palliative care

only)only)

Control of Cerebral Control of Cerebral MetabolismMetabolism

Prevent fits. Prophylaxis in first Prevent fits. Prophylaxis in first week.week.

Phenytoin 15mg/kg loadingPhenytoin 15mg/kg loading Avoid Benzo’s if poss.Avoid Benzo’s if poss. ? Active cooling? Active cooling

Moderate hypothermia (32-33 for Moderate hypothermia (32-33 for 24hrs) of benefit if GCS at 24hrs) of benefit if GCS at presentation5-7presentation5-7

TRANSFERTRANSFER

INTUBATE AND VENTILATE- but don’t INTUBATE AND VENTILATE- but don’t hyperventilate.hyperventilate.

SEDATE WITH PROPOFOLSEDATE WITH PROPOFOL A LINE, CATHETER, ECG etcA LINE, CATHETER, ECG etc Prophylactically- join AAGBI!Prophylactically- join AAGBI! become a member of the Group of become a member of the Group of

Anaesthetists in Training (GAT). Anaesthetists in Training (GAT). Free insuranceFree insurance to cover you during any inter- to cover you during any inter-

hospital ambulance transfers !hospital ambulance transfers !