Traumatic Brain Injury - Core/Disease

Question 1

In TBI patients, how is severity scored in terms of GCS?

Answer 1

Mild - GCS 14-15

Moderate - GCS 9-13

Severe - GCS 3-8

Question 2

What triggers a head CT in trauma patients?

Answer 2

• AMS
• GCS <15 (14 or less)

Question 3

Once TBI is diagnosed, what must be done?

Answer 3

Immediate consultation of neurosurgery team. If no neurosurgery team is available in house, discuss with nearby neurosurgery team and consider transfer.

Question 4

What is an indication for ICP monitoring in TBI patients?

Answer 4

Severe TBI (GCS 3-8)

Question 5

What are goal CPP and ICP in TBI patients?

Answer 5

• Goal CPP - 50-70 mmHg
• Goal ICP - <20-22 mmHg

Question 6

What are standard supportive cares and measures for TBI patients?

Answer 6

• Elevation of HOB
• Analgesics/sedatives
• Avoidence of hyponatremia (Na goal: 145-155)
• Prevention of hyperpyrexia
• Supplemental O2 (maintain Sat >90%, PaO2 >60 mmHg)
• Normocarbic respiration (pCO2 35-40 mmHg)
• Early delivery of nutrition
• Standard trauma cares
  
  • Hemorrhage control/fluid resuscitation/blood products
    
    • ​Goal Hgb >8
  • Correction of coagulopathies
  • Fluid/electrolyte monitoring
  • Treatment for hyper/hypoglycemia

Question 7

In TBI patients, if ICP remains high with appropriate supportive cares and measures, what else can be done?

Answer 7

Tier 1 Interventions

• Additional analgesia/sedation
• CSF drainage

Question 8

In TBI patients, if ICP remains high after tier 1 interventions, what else can be done?

Answer 8

Tier 2 Interventions

• Hyperosmolar Therapy
  
  • Mannitol (0.25-1 g/kg intermittent boluses)
  • Hypertonic Saline (3% NS intermittent boluses)
• Neuromuscular Paralysis
  
  • Nimbex (Cisatracurium)

Question 9

In TBI patients, if ICP remains high after tier 2 interventions, what else can be done?

Answer 9

Tier 3 Interventions

• High Dose Barbituates
• High Dose Propofol

Question 10

In TBI patients, if ICP remains high after tier 3 interventions, what else can be done?

Answer 10

Rescue Strategies

• Decompressive Craniectomy
• Experimental Therapies

Question 11

When should a repeat Head CT be obtained in a TBI patient?

Answer 11

• Discretion/judgment of neurosurgery team
  
  • Often with decline in GCS (drop of 2 or more)
  • Increasing tier intervention

Question 12

What is propofol infusion syndrome?

Answer 12

Characterized by:

• anion gap metabolic acidosis
• cardiovascular compromise
• AKI
• Elevated LFTs

Occurs after prolonged use of propofol

Question 13

What is the treatment for propofol infusion syndrome?

Answer 13

• Cessation of propofol infusion
• Supportive cares:
  
  • HD
  • Hemodynamic support
  • ECMO in refractory cases