head trauma1

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Pediatric Resident Curriculum for the


PICUPICU

HEAD INJURY AND HEAD INJURY AND INTRACRANIAL INTRACRANIAL HYPERTENSIONHYPERTENSION

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PICUPICU

HEAD INJURYHEAD INJURY• Major cause of morbidity and mortality Major cause of morbidity and mortality

in childrenin children• Leading cause of death in children > 1 yr Leading cause of death in children > 1 yr

is traumais trauma• Head injuries responsible for most Head injuries responsible for most

trauma deathstrauma deaths• Adverse outcomes result fromAdverse outcomes result from

– Primary injuryPrimary injury• Result of mechanical forces Result of mechanical forces

producing tissue deformation at the producing tissue deformation at the moment of injurymoment of injury

– Secondary ischemic injurySecondary ischemic injury• Associated with post injury Associated with post injury

hypotension, hypoxemia, and hypotension, hypoxemia, and intracranial hypertensionintracranial hypertension

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PICUPICU

ETIOLOGIESETIOLOGIES• Motor vehicle accidentsMotor vehicle accidents

– Responsible for most severe head Responsible for most severe head injuriesinjuries

• FallsFalls– Usually in children < 4 yrs and Usually in children < 4 yrs and

usually mildusually mild• Recreational activitiesRecreational activities

– Half of these are bicycle accidentsHalf of these are bicycle accidents• Assault or nonaccidental traumaAssault or nonaccidental trauma

– Most head injuries in kids < 1 yr are Most head injuries in kids < 1 yr are from NAT and fallsfrom NAT and falls

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PICUPICU

ANATOMYANATOMY• Uniquely susceptible to injuryUniquely susceptible to injury• BrainBrain

– Inelastic and noncompressibleInelastic and noncompressible– Has no internal supportHas no internal support

• CraniumCranium– Rigid and unyielding after sutures fusedRigid and unyielding after sutures fused– Bony buttresses at anterior poles and Bony buttresses at anterior poles and

temporal polestemporal poles• Membranous “slings”Membranous “slings”

– Falx cerebri compartmentalizes R and L Falx cerebri compartmentalizes R and L hemisphereshemispheres

– Tentorium separates infra- and Tentorium separates infra- and supratentorial regionssupratentorial regions

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PICUPICU MECHANISM OF BRAIN INJURYMECHANISM OF BRAIN INJURY

• Brain is thrown against bony Brain is thrown against bony irregularities or membranous slings irregularities or membranous slings or compressed against these surfaces or compressed against these surfaces by…by…– Contact injuryContact injury

• Head strikes or is struck by an Head strikes or is struck by an objectobject

– Acceleration/deceleration injuryAcceleration/deceleration injury• Violent head motion causes Violent head motion causes

compressive, tensile, and shear compressive, tensile, and shear strain in brain tissuestrain in brain tissue

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PICUPICU COUP - CONTRECOUP COUP - CONTRECOUP

INJURYINJURY

LifeArt: Williams & WilkinsLifeArt: Williams & Wilkinshttp://www.lifeart.comhttp://www.lifeart.com

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PICUPICU TYPES OF PRIMARY INJURIESTYPES OF PRIMARY INJURIES

• Diffuse injuriesDiffuse injuries– Diffuse axonal Diffuse axonal

injuryinjury– Diffuse vascular Diffuse vascular

injuryinjury

• Focal injuriesFocal injuries– Skull fractureSkull fracture– Parenchymal Parenchymal

contusioncontusion– Parenchymal Parenchymal

lacerationlaceration– Vascular injury Vascular injury

resulting in resulting in hematoma hematoma (subdural, (subdural, extradural, or extradural, or parenchymal)parenchymal)

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PICUPICU

SKULL FRACTURESSKULL FRACTURES• Most are uncomplicatedMost are uncomplicated• Basilar skull fracturesBasilar skull fractures

– Battles sign, “raccoon eyes”Battles sign, “raccoon eyes”– CSF rhinorrhea, CSF otorrhea possibleCSF rhinorrhea, CSF otorrhea possible– Cranial nerve injury possibleCranial nerve injury possible

• Depressed skull fractures represent more Depressed skull fractures represent more severe injurysevere injury– 1/3 are associated with dural laceration1/3 are associated with dural laceration– 1/3 are associated with cortical laceration1/3 are associated with cortical laceration– May require surgical elevationMay require surgical elevation

• Fracture crossing path of major vascular Fracture crossing path of major vascular structure increases risk for significant structure increases risk for significant bleedingbleeding– Middle meningeal arteryMiddle meningeal artery– Large dural sinusLarge dural sinus

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•Usually frontal or Usually frontal or temporal lobetemporal lobe•Small cortical Small cortical vessels and neural vessels and neural tissue damagedtissue damaged•Damaged vessels Damaged vessels may thombose, may thombose, leading to ischemialeading to ischemia

CONTUSIONCONTUSION

WebPath: University of UtahWebPath: University of Utahhttp://www-medlib.med.utah.edu/WebPath/webpath.htmlhttp://www-medlib.med.utah.edu/WebPath/webpath.html

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•Usually frontal or Usually frontal or temporal lobetemporal lobe•Can be bilateral Can be bilateral (contracoup injury)(contracoup injury)•Can act as mass Can act as mass lesions and cause lesions and cause intracranial intracranial hypertensionhypertension

INTRACEREBRAL INTRACEREBRAL HEMORRHAGEHEMORRHAGE

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•Usually arterial in originUsually arterial in origin•Between skull and dura, Between skull and dura, limited by suture lineslimited by suture lines•Often from tear in middle Often from tear in middle meningeal arterymeningeal artery•Initial injury may seem Initial injury may seem minor, followed by “lucid minor, followed by “lucid interval,” then neurologic interval,” then neurologic deteriorationdeterioration•May expand rapidly and May expand rapidly and require emergency require emergency craniotomy craniotomy

EPIDURAL HEMATOMAEPIDURAL HEMATOMA


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•Usually venous bleeding Usually venous bleeding (bridging veins)(bridging veins)•On surface of cortex, beneath On surface of cortex, beneath dura and outside arachnoid, not dura and outside arachnoid, not limited by suture lines.limited by suture lines.•Typically requires greater force Typically requires greater force to produce than epidural to produce than epidural hematomahematoma•Usually associated with severe Usually associated with severe parenchymal injuryparenchymal injury

SUBDURAL HEMATOMASUBDURAL HEMATOMA


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PICUPICU

DIFFUSE BRAIN INJURYDIFFUSE BRAIN INJURY• Diffuse axonal injuryDiffuse axonal injury

– Usually from rapid Usually from rapid acceleration/decelerationacceleration/deceleration

– Shear forces disrupt small axonal Shear forces disrupt small axonal pathwayspathways• After disruption, axons degenerate, After disruption, axons degenerate,

fragment, then disappearfragment, then disappear• The neurons then undergo Wallerian The neurons then undergo Wallerian

degenerationdegeneration– Spectrum from mild to severeSpectrum from mild to severe

• Diffuse vascular injuryDiffuse vascular injury– Microvasculature more resistant to shear Microvasculature more resistant to shear

than axonsthan axons– Results in multiple small hemorrhages Results in multiple small hemorrhages

throughout brainthroughout brain– Usually seen in fatal head injuriesUsually seen in fatal head injuries

. ...... . ..

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PICUPICU SECONDARY ISCHEMIC SECONDARY ISCHEMIC

BRAIN INJURYBRAIN INJURY• Compounds the potential for adverse Compounds the potential for adverse

neurologic outcomeneurologic outcome• Caused by:Caused by:

– Post injury hypotensionPost injury hypotension– HypoxemiaHypoxemia– Intracranial hypertension which Intracranial hypertension which

impairs cerebral bloodimpairs cerebral blood flowflow

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PICUPICU INTRACRANIAL INTRACRANIAL

HYPERTENSIONHYPERTENSION• Vascular etiologiesVascular etiologies

– Vasogenic edema Vasogenic edema • BBB impaired, BBB impaired,

protein rich fluid protein rich fluid leaks to ECFleaks to ECF

– Hyperemia Hyperemia • Occurs days 1 to Occurs days 1 to

3 after injury3 after injury– Obstructed Obstructed

venous drainagevenous drainage• Hydrostatic Hydrostatic

pressure pressure increased, increased, protein poor fluid protein poor fluid leaks into ECFleaks into ECF

• Nonvascular etiologiesNonvascular etiologies– Cytotoxic edemaCytotoxic edema

• Ionic gradients Ionic gradients impaired and cells impaired and cells swellswell

– Obstruction to CSF Obstruction to CSF outflowoutflow

– HematomaHematoma– Osmotic brain Osmotic brain

edemaedema• Decreased Decreased

osmolality from osmolality from iatrogenic iatrogenic hemodilution or hemodilution or SIADHSIADH

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PICUPICU INTRACRANIAL INTRACRANIAL

HYPERTENSIONHYPERTENSION• Normal intracranial pressure:Normal intracranial pressure:

– Adults: < 10 mm HgAdults: < 10 mm Hg– Infants/children: somewhat lower, Infants/children: somewhat lower,

depending on agedepending on age• Elevated ICP impairs cerebral Elevated ICP impairs cerebral

perfusionperfusion• Risk for herniation with ICP > 40 mm Risk for herniation with ICP > 40 mm

HgHg• Herniation can occur at lower ICP’s Herniation can occur at lower ICP’s

when mass lesion is presentwhen mass lesion is present

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PICUPICU MANAGEMENT OF HEAD MANAGEMENT OF HEAD

INJURYINJURY• Goals of resuscitation and Goals of resuscitation and

treatment is to minimize treatment is to minimize secondary ischemic brain injury secondary ischemic brain injury by promoting and preserving by promoting and preserving cerebral perfusioncerebral perfusion– Prevent or treat post injury Prevent or treat post injury

hypotensionhypotension– Prevent or treat hypoxemia and Prevent or treat hypoxemia and

reduce oxygen demand of the brain reduce oxygen demand of the brain – Prevent or treat intracranial Prevent or treat intracranial

hypertensionhypertension– Avoid measures that decrease Avoid measures that decrease

cerebral perfusioncerebral perfusion

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PICUPICU

RESUSCITATIONRESUSCITATION• A, B,C’sA, B,C’s• Major early risk is hypotensionMajor early risk is hypotension

– Adequate fluid resuscitation to restore Adequate fluid resuscitation to restore normal BP does NOT worsen neurologic normal BP does NOT worsen neurologic outcomeoutcome

– Avoid hypotonic fluidsAvoid hypotonic fluids• Emergent airway control forEmergent airway control for

– GCS 8 or lessGCS 8 or less– GSC 10 or less with abnormal head CTGSC 10 or less with abnormal head CT– Rapid neurologic deteriorationRapid neurologic deterioration– If needed for other injuriesIf needed for other injuries

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PICUPICU INTUBATION OF PATIENT WITH INTUBATION OF PATIENT WITH

HEAD INJURYHEAD INJURY• Preserve cerebral oxygenationPreserve cerebral oxygenation• Maintain cerebral perfusionMaintain cerebral perfusion

– Adequate analgesia and anxiolysisAdequate analgesia and anxiolysis– Avoid meds that increase ICPAvoid meds that increase ICP– Avoid meds that cause hypotension Avoid meds that cause hypotension – Avoid Trendelenburg positionAvoid Trendelenburg position

• Avoid aggravating C spine injuryAvoid aggravating C spine injury– C-spine injuries in as many as 10% of C-spine injuries in as many as 10% of

head injury patientshead injury patients– In-line axial stabilization by an assistant In-line axial stabilization by an assistant

recommendedrecommended

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PICUPICU DRUGS FOR RAPID DRUGS FOR RAPID

SEQUENCE INTUBATIONSEQUENCE INTUBATION• Analgesia/sedationAnalgesia/sedation

– Fentanyl, Fentanyl, etomidateetomidate• little effect on little effect on

BPBP– ThiopentalThiopental

• decreases ICP decreases ICP but can drop BPbut can drop BP

• AnxiolysisAnxiolysis– MidazolamMidazolam

• little effect on little effect on BPBP

• Lidocaine IVLidocaine IV• blunts blunts

sympathetic sympathetic response to response to intubationintubation

• Neuromuscular Neuromuscular blockadeblockade– Succinyl cholineSuccinyl choline

• short actingshort acting• muscle muscle

fasciculations can fasciculations can increase ICPincrease ICP

• use with use with defasciculating defasciculating dose of dose of nondepolarizingnondepolarizing

– Non depolarizingNon depolarizing• vecuroniumvecuronium• longer acting and longer acting and

no increase in ICPno increase in ICP

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PICUPICU RULE OUT & PREVENT NEUROSURGICAL RULE OUT & PREVENT NEUROSURGICAL

EMERGENCIESEMERGENCIES

• Head CT as soon as possibleHead CT as soon as possible– Initial CT may be normal in severe Initial CT may be normal in severe

head injuryhead injury– Repeat CT in 12 to 24 hoursRepeat CT in 12 to 24 hours

• Moderate hyperventilation advisable Moderate hyperventilation advisable during transport and initial evaluationduring transport and initial evaluation

• If signs of impending herniation If signs of impending herniation develop (lateralizing signs, pupil develop (lateralizing signs, pupil asymmetry)asymmetry)– HyperventilateHyperventilate– Give mannitolGive mannitol

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PICUPICU MONITORING OF INTRACRANIAL MONITORING OF INTRACRANIAL

PRESSUREPRESSURE• Ventriculostomy catheterVentriculostomy catheter

– Catheter tip in frontal horn of Catheter tip in frontal horn of lateral ventriclelateral ventricle

– Can drain CSFCan drain CSF– Can be recalibrated as necessaryCan be recalibrated as necessary

• Transducer tipped catheterTransducer tipped catheter– Intraparenchymal or subduralIntraparenchymal or subdural– Cannot drain CSFCannot drain CSF– Cannot be recalibratedCannot be recalibrated– Exhibits drift in values measured Exhibits drift in values measured

over timeover time

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PICUPICU MONITORING OF INTRACRANIAL MONITORING OF INTRACRANIAL

PRESSUREPRESSURE

• IndicationsIndications– GCS < 8 after resuscitationGCS < 8 after resuscitation– Abnormal head CTAbnormal head CT– Rapid neurologic deteriorationRapid neurologic deterioration

• ICP monitoring is continued for ICP monitoring is continued for as long as treatment of as long as treatment of intracranial hypertension is intracranial hypertension is requiredrequired

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PICUPICU CEREBRAL PERFUSION CEREBRAL PERFUSION

PRESSUREPRESSURE• Can be determined from ICP and mean Can be determined from ICP and mean

arterial pressure:arterial pressure: CPP = MAP - ICPCPP = MAP - ICP

• Calculated CPP does not reflect perfusion Calculated CPP does not reflect perfusion of entire brainof entire brain– CPP further decreased in areas of CPP further decreased in areas of

injuryinjury– Factors that cause cerebral Factors that cause cerebral

vasoconstriction without lowering MAP vasoconstriction without lowering MAP result in a falsely low calculated CPPresult in a falsely low calculated CPP

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PICUPICU CEREBRAL PERFUSION CEREBRAL PERFUSION

PRESSUREPRESSURE

• Goal of therapyGoal of therapy CPP > 60 mm Hg if ICP < 22 mm HgCPP > 60 mm Hg if ICP < 22 mm Hg

oror CPP > 70 mm Hg if ICP > 22 mm HgCPP > 70 mm Hg if ICP > 22 mm Hg

– Lowering ICP while maintaining MAP Lowering ICP while maintaining MAP will increase CPPwill increase CPP

– Increasing MAP will increase CPPIncreasing MAP will increase CPP

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PICUPICU FACTORS AFFECTING FACTORS AFFECTING

INTRACRANIAL PRESSUREINTRACRANIAL PRESSURE• Increases ICPIncreases ICP

– hypercarbiahypercarbia– hypoxia (pOhypoxia (pO2 2 < <

50)50)– seizures or seizures or

shiveringshivering– hyperthermiahyperthermia– arousalarousal

• pain, anxietypain, anxiety– venous venous

congestioncongestion• fluid overloadfluid overload• intrathoracic intrathoracic

pressurepressure

• Decreases ICPDecreases ICP– hyperoxiahyperoxia– hypothermiahypothermia– barbituratesbarbiturates– hypocapniahypocapnia

• via cerebral via cerebral vasoconstrictivasoconstrictionon

• lowers CPP lowers CPP and is and is undesirableundesirable

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PICUPICU EFFECT OF pCOEFFECT OF pCO22 and pO and pO22 ON ON

CBF AND CPPCBF AND CPP• Hypoxia increases Hypoxia increases

CBF by CBF by vasodilationvasodilation

• Hypercapnia Hypercapnia increases CBFincreases CBF

• Hyperventilation Hyperventilation and resulting and resulting hypocapnia hypocapnia decrease CBFdecrease CBF– HyperventilatioHyperventilatio

n is useful to n is useful to prevent prevent impending impending herniation but herniation but will worsen will worsen secondary secondary ischemic injuryischemic injury

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PICUPICU MANAGEMENT OF MANAGEMENT OF

INCREASED ICPINCREASED ICP• Head positionHead position

– Head elevated 30 degrees and Head elevated 30 degrees and midlinemidline

• Sedation and pain controlSedation and pain control– Analgesic + anxiolyticAnalgesic + anxiolytic

• Fentanyl, morphine, or propofol Fentanyl, morphine, or propofol plus a benzodiazepineplus a benzodiazepine

• Continuous infusions or Continuous infusions or scheduled doses to maintain scheduled doses to maintain sedationsedation

– Watch for and treat hypotensionWatch for and treat hypotension• Seizure prophylaxisSeizure prophylaxis

– Phenytoin or phosphenytoinPhenytoin or phosphenytoin

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PICUPICU MANAGEMENT OF INCREASED MANAGEMENT OF INCREASED

ICPICP• Neuromuscular blockadeNeuromuscular blockade

– Facilitates mechanical ventilation Facilitates mechanical ventilation and control of pCOand control of pCO22

– Prevents shiveringPrevents shivering– Use if movement increases ICPUse if movement increases ICP

• Temperature controlTemperature control– A rise in temp of 1A rise in temp of 1oo C increases C increases

cerebral metabolic rate by 10%, cerebral metabolic rate by 10%, increasing ICP by several mm Hgincreasing ICP by several mm Hg

– Maintain temp < 37.5 Maintain temp < 37.5 oo C C• Scheduled acetaminophen, body Scheduled acetaminophen, body

exposure, cooling blanketexposure, cooling blanket

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INCREASED ICPINCREASED ICP• Osmotherapy with mannitolOsmotherapy with mannitol

– Decreases extracellular fluid in brainDecreases extracellular fluid in brain– Intermittent doses for ICP spikes or Intermittent doses for ICP spikes or

scheduled if elevated ICP is persistentscheduled if elevated ICP is persistent– Adverse effects:Adverse effects:

• Hypernatremia, hypokalemiaHypernatremia, hypokalemia• HyperosmolalityHyperosmolality• Hemodilution and drop in hematocritHemodilution and drop in hematocrit• Hypotension Hypotension

– Follow serum osmolality and NaFollow serum osmolality and Na• Hold mannitol if serum osm > 320 Hold mannitol if serum osm > 320

mOsm/lmOsm/l

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INCREASED ICPINCREASED ICP

• Drainage of CSFDrainage of CSF– Possible if ventricular catheter is in Possible if ventricular catheter is in

placeplace– CSF drainage pressure usually set at CSF drainage pressure usually set at

20 cm H20 cm H22OO– CSF drains when ICP exceeds CSF drains when ICP exceeds

drainage pressuredrainage pressure– Ventricular catheters cannot be Ventricular catheters cannot be

placed if cerebral edema has placed if cerebral edema has obliterated or significantly obliterated or significantly compressed ventriclescompressed ventricles

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INCREASED ICPINCREASED ICP

• Second tier therapies for Second tier therapies for intracranial hypertension refractory intracranial hypertension refractory to sedation, muscle relaxation, to sedation, muscle relaxation, osmotherapy, and moderate osmotherapy, and moderate hypothermia:hypothermia:– barbiturate “coma”barbiturate “coma”– induced hypertensioninduced hypertension– decompressive craniotomydecompressive craniotomy– hypothermiahypothermia

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INCREASED ICPINCREASED ICP• Barbiturate “coma”Barbiturate “coma”

– ICP control is the principal endpointICP control is the principal endpoint– EEG burst suppression is a useful EEG burst suppression is a useful

guide to optimal barbiturate dosageguide to optimal barbiturate dosage• Pentobarbital 10mg/kg followed by Pentobarbital 10mg/kg followed by

infusion at 1 mg/kg/hr, titrated to infusion at 1 mg/kg/hr, titrated to effecteffect

• May give additional boluses during May give additional boluses during infusion for acute spikes in ICPinfusion for acute spikes in ICP

• Moderate doses cause sluggishly Moderate doses cause sluggishly reactive pupils while large doses may reactive pupils while large doses may cause mid position to 5 mm cause mid position to 5 mm nonreacting pupilsnonreacting pupils

• Watch for hypotensionWatch for hypotension

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INCREASED ICPINCREASED ICP• Induced hypertensionInduced hypertension

– Inotropes to increase MAP, even Inotropes to increase MAP, even beyond normal for age, to achieve an beyond normal for age, to achieve an optimal CPPoptimal CPP• DopamineDopamine• NorepineprineNorepineprine

– Rise in ICP in tandem with a rise in Rise in ICP in tandem with a rise in MAP implies total loss of MAP implies total loss of autoregulation and is a poor autoregulation and is a poor prognostic signprognostic sign

• Decompressive craniotomyDecompressive craniotomy– Large portion of cranium removed to Large portion of cranium removed to

allow room for brain to swell and allow room for brain to swell and minimize ischemiaminimize ischemia

– Dura must be opened as wellDura must be opened as well

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INCREASED ICPINCREASED ICP• HypothermiaHypothermia

– Core body temp of 32Core body temp of 32oo to 33 to 33oo C C– Reduced cerebral metabolic activity, Reduced cerebral metabolic activity,

reducing ICPreducing ICP– Also has cytoprotective effectsAlso has cytoprotective effects– Adverse effectsAdverse effects

• ArrythmiasArrythmias• CoagulopathiesCoagulopathies• HypokalemiaHypokalemia• Increased risk of infectionIncreased risk of infection

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PICUPICU MANAGEMENT OF OTHER MANAGEMENT OF OTHER

SYSTEMSSYSTEMS• RespiratoryRespiratory

– Maintain normocapniaMaintain normocapnia• Hyperventilation only appropriate during Hyperventilation only appropriate during

early diagnosis and management or if early diagnosis and management or if herniation is impendingherniation is impending

– Maintain oxygenationMaintain oxygenation• pOpO2 2 > 100 is optimal> 100 is optimal

– PEEP to maintain alveolar recruitmentPEEP to maintain alveolar recruitment• ARDS, neurogenic pulmonary edema ARDS, neurogenic pulmonary edema

frequent complicationsfrequent complications• Hypoxemia has more deleterious effects Hypoxemia has more deleterious effects

on brain than modest venous congestion on brain than modest venous congestion caused by PEEPcaused by PEEP

• PEEP of 5 to 10 cm HPEEP of 5 to 10 cm H22O not shown to have O not shown to have detrimental effect on neurologic outcomedetrimental effect on neurologic outcome

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SYSTEMSSYSTEMS• CardiovascularCardiovascular

– Maintain normal blood pressureMaintain normal blood pressure• Hypotension significantly reduces Hypotension significantly reduces

CPPCPP• Inotropes if necessary to maintain Inotropes if necessary to maintain

normal BPnormal BP– Induced hypertension if necessary Induced hypertension if necessary

• GastrointestinalGastrointestinal– Stress gastritis prophylaxis with HStress gastritis prophylaxis with H22

blockerblocker– Jejunal feeds to maintain healthy Jejunal feeds to maintain healthy

intestinal mucosa and prevent intestinal mucosa and prevent bacterial translocation from gutbacterial translocation from gut

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SYSTEMSSYSTEMS• Fluids, Electrolytes, NutritionFluids, Electrolytes, Nutrition

– Goal is NORMOVOLEMIAGoal is NORMOVOLEMIA• Total fluid intake should be @ 100% Total fluid intake should be @ 100%

maintenancemaintenance• Bolus as necessary to achieve normal Bolus as necessary to achieve normal

CVPCVP– Avoid hypotonic fluidsAvoid hypotonic fluids

• Lactated Ringer’s and 0.9% saline w/ Lactated Ringer’s and 0.9% saline w/ 20 mEq KCl/l are good choices for 20 mEq KCl/l are good choices for maintenance fluidsmaintenance fluids

– Follow electrolytes closelyFollow electrolytes closely• Avoid hyponatremiaAvoid hyponatremia• Mannitol can cause electrolyte Mannitol can cause electrolyte

abnormalitiesabnormalities• Watch for SIADH, diabetes insipidus, Watch for SIADH, diabetes insipidus,

cerebral salt wastingcerebral salt wasting

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SYSTEMSSYSTEMS• Fluids, electrolytes, nutritionFluids, electrolytes, nutrition

– Provide calories to meet metabolic Provide calories to meet metabolic demands of patientdemands of patient• Increased metabolic demands during Increased metabolic demands during

acute phase of injuryacute phase of injury• Heavily sedated, relaxed, cooled Heavily sedated, relaxed, cooled

patient has decreased metabolic patient has decreased metabolic demandsdemands

• Enteral feedings via nasojejunal Enteral feedings via nasojejunal catheter preferable to TPN if gut catheter preferable to TPN if gut deemed to be healthydeemed to be healthy

– Avoid hyperglycemiaAvoid hyperglycemia• Associated with poor neurologic Associated with poor neurologic

outcomeoutcome• Watch serum glucose closely if Watch serum glucose closely if

dextrose containing fluids useddextrose containing fluids used

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SYSTEMSSYSTEMS• RenalRenal

– Place foley for strict I’s and O’sPlace foley for strict I’s and O’s

• HematologicHematologic– Coagulopathy common with head injuriesCoagulopathy common with head injuries

• Brain derived thromboplastin activator Brain derived thromboplastin activator substances releasedsubstances released

– Follow PT/PTT or DIC screens Follow PT/PTT or DIC screens – Blood component replacement if evidence Blood component replacement if evidence

of active bleeding or if surgical of active bleeding or if surgical intervention anticipatedintervention anticipated

– Maintain normal hematocrit to optimize Maintain normal hematocrit to optimize oxygen deliveryoxygen delivery

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SYSTEMSSYSTEMS• EndocrineEndocrine

– DIABETES INSIPIDUSDIABETES INSIPIDUS• Complete or partial failure of ADH Complete or partial failure of ADH

secretion from shearing of pituitary stalksecretion from shearing of pituitary stalk• Polyuria, hypernatremia, urine osm < Polyuria, hypernatremia, urine osm <

plasma osmplasma osm• Treatment:Treatment:

Run maintenance fluids @ 100%Run maintenance fluids @ 100%Replace urine output cc for cc with Replace urine output cc for cc with dextrose-containing fluidsdextrose-containing fluidsContinuous vasopressin infusion or DDAVP Continuous vasopressin infusion or DDAVP (subQ or intranasal) q 12 to 24 hrs(subQ or intranasal) q 12 to 24 hrs

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SYSTEMSSYSTEMS• EndocrineEndocrine

– CEREBRAL SALT-WASTINGCEREBRAL SALT-WASTING• ANP-like substance released from brain, ANP-like substance released from brain,

inducing natriuresis and diuresisinducing natriuresis and diuresis

– SIADHSIADH• Elevated level of ADH inappropriate for Elevated level of ADH inappropriate for

prevailing osmotic or volume stimuliprevailing osmotic or volume stimuli• Hyponatremia, hypo-osmolality, urine Hyponatremia, hypo-osmolality, urine

osm > plasma osm, high urine Naosm > plasma osm, high urine Na• Treatment is water restrictionTreatment is water restriction

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PICUPICU

SUMMARYSUMMARY• Identify and treat primary brain injuryIdentify and treat primary brain injury

– Rule out neurosurgical emergencyRule out neurosurgical emergency• Minimize secondary ischemic brain injury Minimize secondary ischemic brain injury

by promoting cerebral perfusionby promoting cerebral perfusion– Maintain normovolemia and adequate BPMaintain normovolemia and adequate BP– Maintain normal electrolytes and Maintain normal electrolytes and

euglycemiaeuglycemia– Maintain normocapnia and adequate Maintain normocapnia and adequate

oxygenationoxygenation– Avoid factors that increase ICPAvoid factors that increase ICP– Treat intracranial hypertensionTreat intracranial hypertension

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