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Management of Severe

Traumatic Brain Injury

Okayama University Graduate School of Medicine,


Dentistry, Pharmaceutical, Sciences
Department of Emergency Medicine
Tetsuya YUMOTO, MD
Japanese cause of death in 2002
Old age Renal Hepatic Diabetes
Accidental 3% failure failure mellitus
injury Suicide 2% 2% 1%
5% 4%
Pneumonia Cancer
11% 37%

Cerebro
-vascular Cardiac
16% disease
19%
Traffic death in Japan
18000
16765

16000

14000

12000 11227
10792 10792 10679

10000 9261 9066


8760

8000
6871
5744
6000

4000

2000

0
1965 1970 1975 1980 1985 1990 1995 2000 2005 2007
Case : 20 y.o. Male
CC: MVA
HPI: Crashed down on to the bank while driving
(more than 100km/hr). (+) Seat belt.
V/S on arrival: HR92/min, BP158/106mmHg,
R30/min, T36.8℃
GCS7 (E1V2M4), pupil (7.0, 4.5mm), LR(-) B/L
CT on arrival ①
CT on arrival ②
Other injuries

Pulmonary
Rt. clavicle fx. contusion B/L

Th5-7 fx.
CT 6 hrs later
Internal & external decompression
Core ICP
Temp
(℃)
Clinical course (mmHg)
38 Barbiturate coma 50

37
40
36

35 30

34
20
33

32 10

31
OR 0

1 2 3 4 5 6 7 8
Follow up CT

day2

day10

day26
TBI
GCS

4~8 9<

AEDH Others ↓GCS


+
Worsening CT findings
(Cool down to 35.5 degrees C)
OR
OR or ICU -

Exclusion criteria
Normothermia + -
Normothermia or
Operation + Normothermia
Active Mild
normothermia hypothermia Guidelines for traumatic brain injury
Showa University Hospital
Management of raised
intracranial pressure
Hyperventilation
Elevating head of bed
Hyperosmotic diuretics
Ventricular drainage
General anesthesia
Barbiturate coma
Hypothermia
Decompression surgery
ICP monitoring
GCS<8
Hypotension (SBP<90mmHg)
CT findings: Midline shift, loss of cistern
Barbiturate coma or hypothermia therapy
Hyperventilation
Temporizing measure for↓ICP.
Should be avoided during the first 24 hours
after injury when CBF is critically reduced.
SjO2 is recommended to monitor.
Elevating head of bed
15 to 30 degrees.
ICP reduction is reported 4.4 to 6.1mmHg at
30 degrees.
Mannitol and glycerol
Insufficient data to support the effectiveness.
Mannitol is effective for control of raised ICP.
Rebound phenomenon.
0.25~1g/kg q6h
We use glycerol more often traditionally.
Barbiturate coma
GCS<8
Uncontrollable ICP (>20mmHg)
With hypothermia therapy
Thiopental: 4~6mg/kg/h
Under mechanical ventilation
Adverse effects: Respiratory and circulatory
depression, hypokalemia
Hypothermia therapy
Under 70 y.o.
GCS≦8
Uncontrollable ICP (20-40mmHg) in spite of other therapies
Except diffuse cerebral swelling

Exclusion criteria: Only acute subdural hematoma,


hemorrhagic shock, thrombocytopenia, severe heart failure or
hepatic failure
Complication and its management
of hypothermia
Complications Management

Hypotension Fluid infusion, catecholamine


Bradycardia Dobutamine, atropine
Arrhythmia Electrolytes, antiarrhythmic agents
Electrolytes disorder Electrolytes disorder
Infection Antibiotics
Thrombocytopenia Platelet transfusion
Shivering Narcotics, muscle relaxants
Management target in hypothermia therapy
Breathing Cerebral perfusion
PaO2>100mmHg ICP<20mmHg
SaO2>98%
CPP>70mmHg
PaCO2: 30~40mmHg
SVO2: 70~80% SjvO2>70%
DO2>600ml/min Others
VO2>150ml/min Hb:10~12g/dl
O2ER:18~25%
AT-Ⅲ>100%
Circulation TP>6.0g/dl
SBP>100mmHg
Alb>3.0g/dl
MAP>80mmHg
CO>5.0l/min
BS:100~150mg/dl
CI>2.5l/min/m2 K:3.5~4.0mEq/l
SVR: 600<, <1500 dynes/sec/cm5 Platelet>50,000/μl
pH:7.30~7.50
Nutritional management
Hypercatabolism, glucose intolerance,
↓bowel peristalsis
GCS<8; 100~140% of BEE (100% of BEE during
barbiturate coma)
Continuous infusion of insulin (BS100~150mg/dl)
Place ED tube in the jejunum
68 y.o. Male c.o. MVA
V/S: GCS8(E3V1M4), HR120/min, BP147/56mmHg,
R26/min, T36.9℃
Early phase
IV contrast CT Parenchymal phase
Laparotomy
-severe hepatic lacerations with IVC injuries
62 y.o. Female c.o. MVA
V/S: GCS11(E2V4M5), HR179/min, BP137/100mmHg,
R30/min, T36.0℃
CT
Plane Early phase Parenchymal phase
Lacerations of Rt. inguinal region
TAE; transcatheter arterial embolization

Deep
circumflex
iliac
artery

Ascending
branch of
Superficial
lateral
epigastric
circumflex
artery
femoral
artery