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4/5/11
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Twyila Lay MS, ACNP-BC Brain and Spinal Injury Center
Unraveling the Mysteries of Traumatic Brain Injury
Who? What? When? Where? Why?
73 year old female with a history of atrial fibrillation on Coumadin. S/P mechanical fall down three steps. (+) LOC, (+) Post-traumatic amnesia, no witnessed seizure activity
GCS in the field 9: E1, V2, M4
ETA to hospital 10 minutes
Glasgow Coma Scale
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Teasdale & Jennett Glasgow University 1974
On presentation ◦ GCS 3 with bilateral fixed and dilated pupils (6mm) ◦ Absent Corneals ◦ Weak Gag
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70% Head Injured Patients Experience a Hypoxic Insult
Vitals ◦ HR: 50 ◦ Blood Pressure: 210/105
Signs of Cushings Triad ◦ Hypertension Widening Pulse Pressure Vasomotor Center ◦ Bradycardia Cardiac Center ◦ Tachypnea Respiratory Center
Cushings Response
Mannitol administered per the Severe Traumatic Brain Injury Guidelines with a return of bilateral pupillary reflexes
With the administration of mannitol her pupillary response returned, and the patient was deemed a surgical candidate.
Patient’s INR: 2.4 ◦ Seven to Ten fold higher risk for development of
Intracranial Hemorrhage ◦ Increased Risks in Setting of Trauma Increased Morbidity and Mortality Hematoma Expansion
Indications ◦ INR due to Warfarin Action ◦ Hemorrhage judged as acutely life, limb or sight threatening ◦ INR >1.5 or clinical evidence the pt is on Warfarin
Contraindications ◦ Uncontrolled Bleeding
Dose ◦ 50 international units x Pt wt in Kg ◦ Round up/down to nearest full vial
Administration ◦ Give over 10 minutes
Onset of Action ◦ 10 minutes
Duration of Action ◦ 24 hours
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Compatibility ◦ Ok to infuse with blood products
Mechanism of Action ◦ Intrinsic pathway of coagulation cascade
Treatment Orders ◦ Bebulin x 1 Dose ◦ DC Warfarin ◦ Vitamin K 10mg IV x 1 dose ◦ FFP x 2 Units
Adverse Reactions ◦ Thrombosis (VTE) ◦ Microvascular complications (lung injury, renal failure)
How Do I Get the Drug ◦ Order form on CHN intranet ◦ Phone to pharmacy “order is coming” ◦ Fax order to pharmacy ◦ Follow up with pharmacy!!! ◦ Send someone to pick up the drug in 20 minutes
Cost ◦ $3000.00/vial
Taken to emergently to the operating room for a right sided decompressive hemicraniectomy
Kocher and Cushing first introduced cranial decompression for intracranial hypertension around the turn of the 19th century
Decompression decreases ICP, improves cerebral oxygenation, and improves CBF
Timing of Decompression ◦ Decompress and evacuate early if there is a
lesion causing obvious mass effect
◦ Consider your therapeutic intensity when considering timing of decompression
SDH with a thickness >10mm or MLS >5mm regardless of GCS
ALL patients with a SDH and a GCS <9 should have ICP monitoring
GCS <9 with a SDH <10mm in thickness and MLS <5mm should undergo evacuation, if the GCS declines between the time of injury and admit by >2 points and/or the ICP is >20 mm Hg
Parenchymal mass lesion and signs of progressive neurologic deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on CT should be treated operatively
GCS 6-8 with frontal or temporal contusions >20cc in volume with MLS >5mm and/or cistern compression on CT scan should be treated operatively
Any lesion >50cc in volume should be treated operatively
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15cm
10cm
“ Go Big or Go Home”
What Happens in the Operating Room?
Risk of infection: 6-8%
Leave incision open to air
Clean surgical site with Normal saline Q12 hours
Bacitracin for the first 72 hours
Keep patient positioned off surgical wound at ALL TIMES
Notify the service ASAP for the following signs of infection
Redness or Swelling Drainage Fever Elevated WBC
Ensure Good Nutrition and Hygiene Practices Daily Showers and Gentle Hair Washing
Wound Healing Vitamins ◦ Vitamin A, C, Zinc
Treatment According to Guidelines
196 Pages Not Friendly
1 Page!!! User Friendly
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VTE Prophylaxis was Started
Options ◦ SCDS (Everyone Should Get These!!) ◦ Pharmaceutical Anticoagulation Lovenox 40mg SQ QD Heparin 5000units SQ Q8
Timing ◦ Patient Dependent
The patient was loaded with Dilantin
Prophylactic Dosing was Inititiated
Who should get prophylaxis? ◦ Patient’s with GCS <10 ◦ Patient’s with
Parenchymal cotusion(s) SDH EDH depressed skull fracture > skull thickness penetrating head trauma seizure within 24 hours of injury
Administer for 7 days unless evidence of
seizure activity
Therapeutic Levels: 10-20mcg/ml ◦ Dilantin (DPH) is highly bound to plasma proteins Albumin (90%)
Side Effects of Dilantin Administration ◦ Hypotension, Bradycardia, and EKG Changes ◦ Severe Thrombophlebitis (Purple Glove Syndrome ◦ CNS depression (nystagmus, somnolence, ataxia
Serum DPH [(0.2 x alb) + 0.1] [DPH] =
*Hypotension (IV) ◦ Administer <25mg/min ◦ Consider fosphenytoin
Skin Necrosis (IV) ◦ Use small gauge needle in large vein ◦ Avoid IV’s in joints ◦ Avoid IV’s >24 hours old ◦ Consider injection of hyaluronidase
Hypersensitivity (IV & PO) ◦ Rash
Blood Dyscrasias (IV & PO)
Food Interations (PO)
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Occur in 35% of all TBI patients
A single episode of hypotension in TBI leads to a Two-Fold increase in Mortality
Three episodes of hypotension leads to a Eight-Fold increase in Mortality
◦ Hypotentison: Systolic blood pressure <90mmHg
Post-operative the patient was taken to the ICU and an Intracranial pressure monitor was placed
Why Measure Intracranial Pressure?
ICP Predicts Outcome
Beyond age and neuro exam, the amount of time ICP > 20 mm Hg is most predictive of outcome
ICP should be monitored in all patients with: ◦ severe TBI (GCS 3-8 after resuscitation) AND ◦ an abnormal CT scan both on admission and on
repeat.
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Patients with severe TBI (GCS 3-8) and a Normal CT scan if 2 or more of the following features are noted upon admission:
age > 40 unilateral or bilateral motor posturing SBP < 90 mm Hg
A combination of ICP values and clinical and brain CT findings should be used to determine the need for treatment
ICP > 20 mm Hg Is it Enough?
Case Study: Multimodal Neuromonitoring for TBI
SjvO2 CBF
PbtO2
EVD
CVP
CBF
EVD
PbtO2
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CBF
EVD
Licox
Monitor Placement
Complimentary information
◦ Local Monitors Brain tissue oxygenation CBF
◦ Hemispheric Monitors SjvO2
PbtO2
CBF SjvO2
Stop Secondary Brain Injury!!!!
Systemic Insults Hypoxia Hypotension Hyper/Hypocapnia Increase Intracranial Pressure Anemia Hyper/Hypoglycemia Acid base disturbances
CBF Brain Tissue Oxygen
Early Detection low PaO2
Tailor CPP management
Optimize Hyperventilation
Early Detection of Imminent ICP Elevation
PbtO2
By POD#4 all the patient’s monitors were able to be discontinued and she was successfully transferred to the floor
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No monitoring available ◦ Emphasis on following trends
Neurological exam GCS
Transition 1:1 nursing to a nurse ratio of 1:4 ◦ Patient and Family Expectations
Agitation & Patient Frustration with Recovery
Changes in Medication Regimen ◦ Narcotic Wean
Often rapid wean when transferring from ICU to floor Expected Wean 10% per Day
Enhanced Communication
Stimulation Control ◦ Balance between sensory overload and deprivation
Environmental Modifications ◦ **Key
Rancho Los Amigos Scale ◦ Awareness of current stage in the recovery process ◦ Turn to your “COWS”
Pt is increasingly agitated
Sweating
HR increased to 130
BP 160/90
Febrile 39.2°C
M: Metabolic O: Oxygenation V: Vascular E: Endocrine/Electrolytes/Environment S: Seizures T: Trauma/Tumor/Temperature U: Uremia P: Psychiatric I: Infection D: Drugs
Labs return with Sodium Level of 129Meq/L
Na+
Normal Sodium: 134-145mEq/L Most likely to Occur in Patient’s with Large
Contusions Symptoms ◦ Confusion ◦ Agitation ◦ Seizures ◦ Coma
Diagnosis ◦ Assess Volume Status ◦ Urine Output ◦ Labs
Uosmo Sosmo Chem 7
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CSW (salt loss)
Volume Depletion
Volume Expanded
SNa+ <135 Sosmo <280
Una+ >20mEq/L
SIADH (H2O retention)
Fluid Replacement +
Salt Tabs Fluid
Restriction
Failure to distinguish CSW from SIADH in a hyponatremic patient with a brain injury will lead to inappropriate therapy and potentially exacerbate morbidity and mortality
Monitor Intake and Output
Replacement of both fluids and sodium ◦ Hydration with Normal Saline ◦ Na+ replacement First line is 3% @ 20-90 cc/hr NaCl 3gms Q6-8 Florinef 0.1-0.2mg PO Daily
Follow serum sodiums closely
Pt is obtunded GCS 12 now 8
What are your concerns and interventions?
What are your Priorities?
Respiratory insult ◦ Infection, PE, Hypoventilation
Infection ◦ Hypotension, Fever, Sepsis
Toxic Metabolic ◦ Hyponatremia
Seizures
Hydrocephalus New Bleed ◦ Head CT
Apply O2 via Face Mask
Position on side to prevent aspiration
DO NOT try to insert and airway
Establish an IV, Prepare to administer benzodiazepines and anti-epileptic medications
Ensure patient safety
Institute seizure precautions
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Formal Presentation at Interdisciplinary Team Rounds (IDT) ◦ Neurosurgery ◦ Social Work ◦ Rehab Services (PT,OT, ST, PM&R) ◦ Nutrition ◦ Eligibility ◦ Utilization Review ◦ Neurotrauma Outreach ◦ Neuropsychology ◦ Clinical Nurse Specialist ◦ Nursing
The patient was considered to be medically stable and ready for Discharge
Acute Rehabilitation ◦ Follows 90% of Commands Consistently ◦ Tolerate 2-3 hours of combined rehabilitation a day ◦ Must require Physical therapy and one other rehab
discipline ◦ Average Stay 2-3 weeks
Skilled Nursing Facility Rehabilitation ◦ Follows 75% of commands ◦ Tolerate 1-2hours of combined rehab in one day ◦ Average Stay <2 months
Long-Term Skilled Nursing Facility ◦ Require Care >2 months
◦ Skilled needs for this level of care include Feeding Tube Rehabilitation Services
Patients can receive rehabilitation services at this level if they are actively participating and making gains
◦ A patient becomes "custodial" when they don't have any skilled needs but require twenty-four hour care and can't go back to the community Patients can stay in this level of care for their lifetimes
Subacute Care ◦ This level of care is for patients who are on a
ventilator or have a tracheostomy tube and a feeding tube
The purpose of these facilities is to wean patients off of their tracheostomies, if possible, and to transition them on to either rehabilitation or to a long term care facility
There is a shortage of this level of care in Northern California
Neurosurgery Clinic
Traumatic Brain Injury Clinic
Concussion Clinic
Neurotrauma Outreach Program (NTOP)
TBI Support Group
Immediate Hospital DC Follow-up
Every Tuesday Morning
Appointment Scheduling ◦ eReferral ◦ Direct Phone Line (415) 206-4420
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Mission ◦ To provide transdisciplinary care for the patient with traumatic
brain injury enhancing overall recovery, facilitating reintegration into the community, promoting emotional well-being, and providing supportive educational information.
Trans-Disciplinary Team
First Thursday of Every Month
Appointment Scheduling ◦ eReferral
Mission ◦ To provide multidisciplinary and supportive care for
the patient with mild traumatic brain injury thru post-concussive assessment and symptom targeted patient education
Multi-disciplinary
Third Thursday of Every Month
Appointment Scheduling ◦ eReferral
Emphasis upon assertive tracking, outreach, and engagement into services
Clinical case management to address all basic needs (medical, legal, financial, housing, services etc.)
Coordination of care across medical, psychiatric, psychosocial, rehabilitation and social services
Evidence-based psychotherapy to target psychiatric distress, increase interpersonal safety and help clients cope with the cognitive and behavioral changes associated with TBI.
Currently employees ◦ Neuropsychologist ◦ Two full time licensed Social Workers
Statistics ◦ NTOP provides services to 200 TBI patients annually
with approximately 100 of those patients receiving more in-depth outreach services
Mission: ◦ To provide emotional support and education to TBI
patients and their families who are living with a traumatic brain injury.
What does the TBI Support Group Provide ◦ Traumatic Brain Injury Education ◦ Peer Support and Mentoring ◦ Community resource referrals ◦ Invited speakers from numerous specialties
(Neurology, Nutrition, Sleep, Rehabilitation, ect).
Post-concussive Symptoms
Need for Neuropsychology Testing
Psychosocial Issues
Reintegration in the Community
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More than 75% of all Mild TBI patients report 1or more Symptoms
Signs and Symptoms ◦ Physical
◦ Cognitive
◦ Emotional
◦ Sleep
Patient Education ◦ Pt’s who receive education around the s/s of concussion
and the trajectory of recovery experience fewer symptoms overall Folders
Leaders in Traumatic Brain Injury care
ICP Monitoring in patients with GCS <8
Seizure Prophylaxis
VTE Prophylaxis
IDT Review
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TBI Program - NSU StatsMay 2010 - December 2010
(509 Total Patient Encounters)
Random Sample of TBI Chart Audits
TBI Program2010 Performance Improvement
Intracranial Pressure (ICP) Monitoring
Quality Indicator: Intracranial Pressure (ICP) Monitoring
Random sample of patients who have sustained a moderate to severe head injury and have a GCS < 8
The following patients are excluded: death/comfort care, improving GCS / exam, coagulopathy, otherclinical indications
TBI Program2010 Performance Improvement
Seizure Prophylaxis
Quality Indicator: Seizure Prophylaxis (7 days of anti-seizure medication)
Random sample of patients with TBI and abnormal CT scan
The following patients are excluded: isolated subarachnoid hemorrhage, clinical contraindication
TBI Program2010 Performance Improvement
DVT Prophylaxis
Quality Indicator: DVT Prophylaxis
Random sample of patients with TBI
The following patients were excluded: ambulatory, coagulopathic, other clinical contraindications
TBI Program2010 Performance Improvement
Interdisciplinary Team ( IDT) Rounds
Quality Indicator: Interdisciplinary Team (IDT) Rounds
Random sample of admitted TBI patients who have sustained a mild, moderate, or severe head injury
The following patients are excluded: hospital length of stay (LOS) < 7 days
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www.brainandspinalinjury.org Questions?
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