Emergency nursing talk on resuscitating the injured brain- focusing on the little things- that make a difference to morbidity and mortality.

1. Resuscitating the
Injured Brain
“It’s the little things that matter”
By Kane Guthrie

2. Learning Points
 How to resuscitate the injured brain.
 A case.
 Understanding of primary Vs secondary injury.
 Learn about the little things that make a difference in TBI.

3. Traumatic Brain Injury
 Leading cause of death in children and young adults!
 Main cause of lifelong disability after trauma!
 Optimal early Mx can have profound effect on their
prognosis!
 What we do downstairs can make the difference upstairs!

4. Case Study
 27 male
 1x punch to head, LOC, hit
ground.
 GCS 5/15
 Intubated and sedated.
 Taken to the doughnut.
 Now what?

5. The PathO!
Primary Secondary
 Physical damage to  Complex process.
parenchyma.  Results from primary injury
 Occurs during traumatic event. and acute disorder that occur
 Results in from this.
shearing/compression of brain 1. Hypotension
tissue. 2. Hypoxia
3. Hypo/Hypercarbia
 Not Reversible!
 Preventable and reversible!

6. The Types
Primary Secondary
Extra-axial: Acute:
 Epidural haematoma  Diffuse cerebral swelling
 Subdural haematoma  Brain herniation
 SAH  Infarction
 Intraventricular Haematoma  Infection
Intra-axial: Chronic:
 Axonal injury  Hydrocephalus
 Cortical contusion  CSF leak
 ICH

8. The @ risk groups!
 The Elderly
 Infants
 The anticoagulated
 Chronic alcoholics

9. The other Lethal Triad!
or
or

10. Our Goals in ED
 Resuscitate & assess for other injuries.
 Prevent & treat raised ICP & secondary brain insults.
 Avoid hypoxia & hypotension.
 Preservation of CPP.
 Optimisation of cerebral oxygenation.

11. The Big Things
Focus on correcting/preventing secondary brain insults:
 Avoid Hypoxia and Hypotension
 Prevent ∧ICP & impaired cerebral perfusion
 Reverse anticoagulation
 Protect and secure airway
 Rule out C-spine injuries

12. The Algorithm

13. The Little Things!!

14. Once the big things are done:
Its time to optimise:
 Pt Position
 Cervical collar
 Temperature
 BP
 Seizure prophylaxis
 Glucose

15. Patient Position
 Elevate the head of bed to 30-45°C.
 Decreases ICP by:
 Displacing the CSF.
 Increasing venous outflow.
 Also decrease risk of VAP!
 Use reverse trendelenburg if cervical spine an issue!

16. Trendelenburg Position.
 Time honored tradition for the hypotensive Pt.
 More harm than good.
 May give transient rise in BP.
But:
 Raise’s ICP through venous congestion.
 Worsen hypotension pushing abdo organs in thorax decrease
venous return to heat.
 Alter ventilation & perfusion.

17. Securing the Tube
 Tape Vs Ties
 Ties can constrict venous
return and raise ICP.
 Best to avoid!

18. Cervical Collar
 AKA the “BRAIN TOURNIQUET”
 Removal ∨ ICP by 2-5 mmHg.
 If unable to remove – loosen enough so it aids venous
return!

19. Temperature Mx
 Therapeutic hypothermia – no good evidence yet. (POLAR
study just starting)
 Fever is bad :
 ∧ oxygen consumption
 ∧ cerebral metabolic rate.
 We SHOULD focus on therapeutic normothermia!
 Monitor closely and keep temp <37°C.

20. Blood Pressure Mx
 Abnormal BP is common!
 Hypotension = detrimental & needs to be treated
aggressively – maintain CPP.
 Hypertension can occur due to raised ICP, medical
condition, or pain & anxiety.
 Use sedative/analgesia first line if intubated.
 Rarely use short acting antiHT and dose gingerly to avoid
hypotension and ∨CPP.
(Archives of Surg 2001:136;1118-1123)

21. Cerebral Perfusion Pressure
 CPP = MAP – ICP.
 Elevated ICP - leads to loss of CPP – leading irreversible
brain damage.
 Difficult to measure ICP & CPP in the ED.
 Focus on avoiding hypoxia and hypotension.
 Aim for Spo2>90 & BP> 90 with target MAP >70mmHg
gives you an estimate of CPP of around 50-70mmHg.

22. Seizure Prophylaxis
 Limited evidence to support practice!
However:
 The injured brain that's seizing isn’t a good sign.
Give prophylaxis:
 Phenytoin
 Levetiracetam (Keppra).

23. Glucose Mx
 Controversial topic in critical care!
 Hyperglycaemia in TBI generally = poor neuro function.
 Hypoglycaemia is bad – brain obligate glucose consumer.
 Studies show intensive insulin therapy - more hypo’s &
?increase mortality.
Take home point:
 Treat Pt’s with marked hyperglycaemia but avoid
hypoglycaemia. Aim for BSL 8-12mm0L

24. In Summary
1. Avoid hypotension & hypoxia at all cost!
2. Sit them up decreases ICP & VAP!
3. Keep a close eye on the BP, BSL & Temp!
4. Try and clear the neck early and tape the tube!

25. Remember
What YOU do matters!
 Mel Herbert.

26. But!