pathophysiology of acute traumatic … · the$monro–kellie$doctrine. cpp= map-icp. primary damage...
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PATHOPHYSIOLOGY OF ACUTE TRAUMATIC BRAIN INJURYDr Nick TaylorMBBS FACEM
The Monro–Kellie Doctrine
CPP=MAP-ICP
PRIMARY DAMAGE
• TBI is a heterogeneous disorder • Brain damage results from external
forces, as a consequence of direct impact, rapid acceleration or deceleration, penetration or blast waves• The nature, intensity, direction, and
duration of these forces determine the pattern and extent of damage.
MACROSCOPIC DAMAGE
•On the macroscopic level, damage includes shearing of white-matter tracts, focal contusions, haematomas and diffuse swelling
DAI
•DAI is characterised by multiple small lesions in white-matter tracts. • Patients with DAI are usually in
profound coma as a result of the injury, do not manifest high ICP, and often have a poor outcome.
BLEEDING
• Focal cerebral contusions are the most common traumatic lesion, are more frequent in older patients, and usually arise from contact impact. • Traumatic intracranial haematomas
occur in 25–35% of patients with severe TBI and in 5–10% of moderate injuries
CELLULAR LEVEL
• Early neurotrauma events include microporation of membranes, leaky ion channels, and stearic conformational changes in proteins. •At higher shear rates, blood vessels
can be torn, causing (micro)haemorrhages.
ISCHAEMIA
• Ischaemic brain damage is often superimposed on the primary damage and can be widespread or, more commonly, perilesional.• Impaired cerebral perfusion and oxygenation,
excitotoxic injury, and focal microvascular occlusion can be contributing factors.
ISCHAEMIA
•Although the total ischaemic brain volume may be less than 10% on average, the presence of cerebral ischaemia is associated with poor ultimate neurological outcome, that is, dead or vegetative state
SECONDARY INJURY
• Each type of head injury initiates different pathophysiological mechanisms, with variable extent and duration • Secondary processes develop over hours and
days, and include neurotransmitter release, free-radical generation, calcium-mediated damage, gene activation, mitochondrial dysfunction, and inflammatory responses.
EARLY SECONDARY INJURY
• The first stages of cerebral injury after TBI are characterized by direct tissue damage and impaired regulation of CBF and metabolism. This ‘ischaemia-like’ pattern leads to accumulation of lactic acid due to anaerobic glycolysis, increased membrane permeability, and consecutive oedema formation. • Since the anaerobic metabolism is inadequate to
maintain cellular energy states, the ATP-stores deplete and failure of energy-dependent membrane ion pumps occurs.
LATER INJURY
•Glutamate and other excitatory neurotransmitters exacerbate ion-channel leakage, worsen astrocyticswelling, and contribute to brain swelling and raised ICP. • Neurotransmitter release continues for
many days, paralleling the course of high ICP, and, with free-radical and calcium-mediated damage, is a major cause of early necrotic cell death
INFLAMMATION: 2 EDGED SWORD
• Inflammatory response is an important component of TBI, particularly around contusions and (micro) haemorrhages. • The maximum response occurs within a few days,
but cytokines are released within hours after TBI, leading to opening of the BBB, activation of cell death and apoptosis. • Although the inflammatory response can be
deleterious in excess, it is necessary in order to clean up cellular debris after injury
MITOCHONDRIA
• Recent research has raised new insights that challenge existing concepts of pathophysiology.•Mitochondrial dysfunction can cause
energy failure after TBI, with a decrease in production of ATP and consumption of oxygen by 40–50%. This can trigger apoptosis and necrosis.
MITOCHONDRIA
• Mitochondrial dysfunction might also lead to axonal disruption. The classical concept that DAI is due to mechanical rupture of axons, incompatible with regeneration or repair, has now been abandoned.• Neurons can at least partially regenerate their
axonal anatomy. This accords with clinical observations• Lab work has shown that DAI can take up to 48
hours to become fully established and is thus amenable to therapeutic interventions.
CEREBRAL BLOOD FLOW
•Whether decreased cerebral blood flow (CBF) after trauma is indicative of ischaemia or is secondary to metabolic depression remains the subject of debate.•Cerebral hemodynamics change
significantly post injury,and the pattern of these changes depends upon the type of injury and its severity
CBF
• The critical threshold of CBF for the development of irreversible tissue damage is 15 ml 100 g−1 min−1 in patients with TBI compared with 5–8.5 ml 100 g−1 min−1 in patients with ischaemic stroke.• This is likely because of the other brain
damage occurring in TBI vs CVA
CBF
• Patients with TBI may develop cerebral hyperperfusion (CBF >55 ml 100 g−1 min−1) in the early stages of injury. • Likewise, hyperaemia may follow immediate post-
traumatic ischaemia. • This pathology seems as detrimental as ischaemia
because increases in CBF beyond matching metabolic demand relate to vasoparalysis leading to increases in cerebral blood volume and in turn intracranial pressure (ICP).
CBF AUTOREGULATION
• After TBI, CBF autoregulation is impaired or abolished in most patients. • Defective CBF autoregulation may be present
immediately after trauma or may develop over time, and is transient or persistent in nature irrespective of the presence of mild, moderate, or severe damage. • Also, autoregulatory vasoconstriction seems to be
more resistant compared with autoregulatory vasodilation which indicates that patients are more sensitive to damage from low rather than high CPPs
CO2 RESPONSIVENESS
• Compared with CBF autoregulation, cerebrovascular CO2-reactivity seems to be a more robust phenomenon.• In patients with severe brain injury and poor
outcome, CO2-reactivity is impaired in the early stages after trauma. • In contrast, CO2-reactivity was intact or even
enhanced in most other patients offering this physiological principle as a target for ICP management in hyperaemic state
PRINCIPLES OF MX• Trauma renders the brain more
vulnerable to insults, and hypoxia and hypotension are strongly associated with poor outcome (hypoxia: odds ratio [OR] 2·1, 95% CI 1·7–2·6; hypotension: OR 2·7, 95% CI 2·1–3·4• Treat the patient (but consider the
impact this will have on their brain)
PRINCIPLES
• Protect the brain from secondary injury•Maintain CPP (by maintaining MAP
and reducing ICP)•Maintain oxygenation• Prevent complications•Arrange timely interventions
HOW DO WE SAFELY INTUBATE
• Protect the C-spine•Avoid hypotension• IVF load first • Judicious induction drug doses
based on patient characteristics• Eg • Propofol/Thio low dose (0.5-1mg/kg)• Fentanyl 3-5 mcg/kg • Ketamine (Theoretical raised ICP vs
absolute risk hypotension)• Combinations
• Have metaraminol drawn up and ready
HOW DO WE SAFELY INTUBATE
• Avoid hypertensive spikes• Avoid prolonged, multiple attempts
(experience)• Consider fentanyl• Paralyse for transport
• Avoid hypoxaemia• Pre O2•Maximise your first attempt success• Have a back up plan and rapidly use it
WHAT ELSE SHOULD WE DO
TREATING RAISED ICP
Crack the box
Assist venous outflow
Reduce brain water
Control arterial inflow
Drain the extra blood
Reduce the CMR
DRAIN THE BLOOD, CRACK THE BOX
• Urgent CT scan is used to stratify patients who need emergency neurosurgery• Surgically drainable blood is a priority
for OT• Decompressive craniectomy is
controversial, (DECRA inconclusive) but used with high ICP and no drainable blood
CONTROL THE INFLOW
• Keep MAP >80 (ideally with ICP monitor in , keep CPP>60)
• Avoid SBP <90
• Keep PaCO2 low normal • CO2 is a cerebral vasodilator• Reducing CO2 below normal ranges causes
vasoconstriction and worsens secondary ischaemia
• Can acutely hyperventilate to a lower number if herniation suspected
ASSIST VENOUS OUTFLOW
•Head up 30 degrees (incline whole bed)•Avoid tight hard collars•Avoid tight tube ties
REDUCE BRAIN WATER• Avoid free water: N/Saline only (NOT
dextrose, NOT albumin)• Osmotherapy agents• Mannitol: Exact mechanism unknown;
multiple studies showing efficacy• Rebound phenomena exist• Hypotension may be worsened• Eg 0.5-1g/kg
• Hypertonic Saline:• Mobilises water across intact BBB via osmotic
effect; may increase local blood flow, may have anti inflammatory effect
• Good theory, used widely, solid evidence lacking
• Eg 100mL 3% saline , esp if hypotension
REDUCE THE CMR
• Hypothermia• Evidence for prophylactic hypothermia has
failed to find a mortality benefit despite early promise but may increase infection. The jury is still out
• Barbituate coma• Recommended for refractory ICP Mx in ICU• Assoc with signif increased VAP and K+
morbidity
OTHER STUFF
• Steroids• Unsurprisingly the CRASH study
showed patients did worse•Glutamate / Lipids/ anti free
radicals• Maybe
•Mg2+ the magic elixir• No
•Antifibrinolytic drugs• Need more info
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