Embed Size (px)
Citation preview
Evidence-Based Management of
Severe Traumatic Brain Injury
DR. YASEEN ARABI
Chairman
Intensive Care Department
King Abdulaziz Medical City - Ministry of National Guard
Riyadh, Kingdom of Saudi Arabia
Basic Concepts
Secondary Brain Insults
Summary of Guidelines
Transforming the knowledge into practice: Head Injury Protocol
DECRA trial
Epo-TBI trial
Basic Concepts
Time
0 24 h 48 h 72 h
Initial Insult Inflammation and Ischemia
Secondary Brain Insults
Systemic SBI
Hypotension
Hypoxia
Hypercapnia
Hypocapnia
Anemia
Hypertension
Hyperglycemia
Hyponatremia.
Secondary Insults- Intracranial
Hematoma
Increased ICP
Edema
Vasospasm
Hydrocephalus
Infection
Seizures
Brain Trauma Foundation
The American Association of Neurological Surgeons
The joint Section on Neurotrauma and Critical Care.
(WHO) Committee on Neurotraumatology (endorsed).
The Primary Goal of ICU
Management is Prevention of
Secondary Insults
BP Management
BP Goal is MAP>80-90 and CPP>60
This is achieved by fluids until euvolemia.
Fluid of Choice: NS.
NO D5W or hypotonic fluids are allowed. Ringer’s lactate is slightly hypotonic.
If BP goal is not achieved by fluids use vasopressors: Norepinephrine is 1st choice.
Indications for ICP Monitoring
A. Standard: insufficient data.
B. Guidelines:
ICP is appropriate: S.H.I + abnormal CT scan.
ICP is appropriate: S.H.I + normal CT scan + 2 of:
age > 40 years.
uni- or bilateral motor posturing.
SBP < 90 mm Hg.
ICP is not routinely indicated: mild or moderate H.I.
ICP Treatment Threshold
A. Standard: insufficient data.
B. Guidelines: ICP treatment should be initiated at an upper
threshold of 20-25 mm Hg, 5min
C. Options: interpretation & treatment based on frequent
clinical examination and CPP data.
Hyperventilation
A. Standards: In the absence of increased ICP, chronic
prolonged hyperventilation (PaCO2 25 mm Hg) should
be avoided.
B. Guidelines: Prophylactic hyperventilation (PaCO2 35
mm Hg) during the first 24 H after severe TBI should be
avoided.
C. Options: Hyperventilation may be necessary for brief
periods (acute neurologic deterioration) or for longer
periods (refractory ICHT), SjO2 + TCD monitor.
Cerebral Perfusion with Hyperventilation
CTscan PaCO2 38 PaCO2 25
Marion. New Horisons 1995
Use of Mannitol
A. Standards: Insufficient data.
B. Guidelines: Mannitol is effective for control of raised ICP
after S.H.I (0.25 – 1 g/kg).
C. Options:
1. Indications for mannitol prior to ICP: signs of
transtentorial herniation or progressive neurologic
deterioration. (Prophylactic use of mannitol is not
recommended).
2. Serum osmolarity should be kept below 320 mOsm.
3. Euvolemia should be maintained by adequate fluid
replacement.
Use of Barbiturates in the
Control of ICHT
A. Standards: Insufficient data
B. Guidelines: High-dose barbiturate therapy may be
considered in hemodynamically stable salvageable
S.H.I patients with ICHT refractory to maximal medical
and surgical ICP lowering therapy.
Role of Steroids
A. Standards:
The use of steroids is not recommended for improving outcome or reducing ICP in patients with S.H.I.
A. Guidelines: None
B. Options: None.
Anti-seizure Prophylaxis
A. Standards:
Anti-seizure prophylaxis is NOT recommended forpreventing late post-traumatic seizures.
A. Guidelines: None
B. Options:
Anticonvulsants may be used to prevent EARLY post-traumatic seizures in patients at high risk for seizuresfollowing head injury.
Medical Knowledge Real Life Practice
Real Life ? !
Hesdorffer. J of Trauma. 2002.
*4 patients are still in the hospital.
Before
Protocol
After
Protocol
P-Value
ICU Mortality 31 (22.8%) 12 (9%) 0.002
Hospital
Mortality
41 (30.2%) 17 (12.7%)* < 0.001
KAMC Protocol for Traumatic Brain Injury
ICU Mortality by ICP Placement
Before
Protocol
After
Protocol
P-Value
ICP not placed 24/103
(23.3%)
11/119
(9.2%)
0.004
ICP placed 7/33
(21.2%)
1/15
(6.7%)
0.21
The protocol and Outcome
Using univariate analysis, the protocol significantly
improved the chances of survival (OR 3.0, CI 1.47-6.14,
P=0.002)
Using multivariate analysis, the improvement of outcome
with the protocol was independent of ISS or severity of
illness measures.
The presence or the absence of ICP did not have an
impact on outcome.
Early Decompressive Craniectomy in
Traumatic Brain Injury “DECRA TRIAL”
Bilateral cruciate incisions
Intracranial Pressure Before and
After Randomization
Primary and Secondary Outcome
Alfr
ed
Sa
ud
iO
ther
0 .2 .4 .6 .8 1Proportion of unfavourable outcomes
Alfr
ed
Sa
ud
iO
ther
.1 1 2OR
Participating Centres
AUSTRALIA
Canberra Hospital
John Hunter Hospital
Liverpool Hospital
Nepean Hospital
Royal North Shore Hospital
Royal Prince Alfred Hospital
St Vincent's Sydney
Westmead Hospital
Gold Coast Hospital
The Townsville Hospital
Royal Adelaide Hospital
Royal Hobart Hospital
The Alfred Hospital
The Royal Melbourne Hospital
Royal Perth Hospital
NEW ZEALAND
Auckland City Hospital
Christchurch Hospital
Wellington Regional Hospital
Dunedin Hospital
KINGDOM OF SAUDI ARABIA
King Fahad National Guard Hospital
FRANCE
Hôpital de Bicêtre
Hôpital Lariboisière
Hôpital Michallon
Hôpital Purpan
Hôpital Rangueil
Hôpital Caremeau
Hôpital Charles-NicolleFINLAND
Helsinki University Central Hospital
Kuopio University HospitalIRELANDBeaumont Hospital
GERMANY
Johannes Gutenberg Universtität
Study Procedures
Summary of trial treatment and follow up schedule. The baseline ultrasound
may be performed before or at least within 48 hours after the first dose
administration. EPO, Erythropoietin (Epoetin alfa) 40,000 IU or normal saline
placebo; US, Ultrasound.
No Effect on Primary Outcome:
GOSE 1-4 vs 5-8
EPO Placebo
Relative
Risk
(95% CI)
Risk
Differenc
e % (95%
CI)
p value
134/302
(44·4%)
132/294
(44·9%)
0·99
(0·83 to
1·18)
-0·5
(-8·5 to
7·5)
0·90
No Increase in Lower Limb DVT: RR
0.87 (95% CI 0.61 – 1.24)
All Patients
(n=603)
Erythropoietin
(n=305)
Placebo
(n=298)p value
102/603
(16·9%)48/305 (15·7%)
54/298
(18·1%)0·44
EPO May Reduce Mortality – K-M
Survival Curves
RR 0·68, 95% CI,
0·44 to 1·03;
ARR 5% ,
-10·4% to 0·4%
Hazard Ratio
0.65 (95% CI
0.42 to 1.02)
p=0.06
