Role of the Critical Care
Surgeon in Traumatic Brain
Injury
Jon C. Krook, M.D., F.A.C.S.
Department of Surgery
HCMC
Case Presentation #1
• 55 y.o. female, MCA at highway speeds
with no helmet
– Was cut off by an auto and “laid” the bike
down, was thrown from the bike
– Was initially awake and talking to the first
responders but became confused
– 10-15 minutes later L pupil became fixed
and dilated
– Intubated and transported to HCMC
Admission CT
Post-operative CT
Post-operative CT #2
Case Presentation #2
• 23 y.o. in the Air Force, suffered an
accidental GSW to the left side of the
head
• Initially managed at another hospital
and then transferred to HCMC
Outside Hospital CT
Outside Hospital CT PID#1
HCMC Arrival CT
Initial assessment
Initial evaluation of the Brain
Injured Patient
• ATLS primary and secondary survey
ATLS Primary Survey
A
B
C
D
E
Airway
Breathing
Circulation
Disability
Exposure
• Avoid hypoxia and hypotension
– Need to prioritize injury management
Initial evaluation of the Brain
Injured Patient
• ATLS primary and secondary survey
–A–B–C– D– E-
Intubate if GCS < 8 or other
indication
Rule out injury
Evaluation/Treatment of shock
Evaluation of mental status
Look for other injuries
– Secondary survey- comprehensive
physical exam
Initial evaluation of the Brain
Injured Patient
• Imaging
– Chest, pelvic, +/- c-spine x-rays
– FAST exam
– Head CT
• + LOC
• Altered mental status on evaluation
• Surgery
– Head or other
• Prioritization
General critical care concepts
specific to the head injured
patient
Critical Care Evaluation
• All early management of the head
injured patient is aimed toward limiting
secondary brain injury
• Avoid hypotension or hypoxia
• Preserve oxygen delivery to the
uninjured brain
Monro/Kellie Doctrine
Brain
CSF
Blood
Herniation
• Supertentorial Herniation
–
–
–
–
1 Uncal (transtentorial)
2 Central
3 Cingulate (subfalcine)
4 Transcalvarial
• Infratentorial
– 5 Upward (upward
cerebellar)
– 6 Tonsilar (downward
cerebellar)
http://en.wikipedia.org/wiki/Brain_herniation
Intracranial Pressure
Monitoring
• Types
– Bolt (subdural screw)
– Epidural sensor
– Ventriculostomy
• Diagnostic
• Therapeutic
Cerebral Perfusion Pressure
CCP= MAP - ICP
Preserving MAP
• Can be challenging in the face of other
injuries
– Shock
• Hypovolemic/hemorrhagic
• Cardiogenic
• Neurologic
• Vasopressors
– Can have downsides
• May increase driving pressure, but may
decrease overall blood flow to the brain
Lowering ICP
• Options
– Sedation
– Draining CSF
– Hyperosmolar therapy
Triangle of ICU Sedation
Analgesia
Anxiolytics/Sedation
Paralytics
Delirium
Sedation
• Propofol
– Rapid onset, short duration of action
• Important in awaking trials
– Depresses cerebral metabolism
– Reduces cerebral oxygen consumption
– Possibly reduces ICPs through direct
methods
Sedation
• Fentanyl
– Rapid onset, short duration of action
– Usually given as a drip
• Some evidence of worsening of CCP (BP,
ICP) with bolus
Hyperosmolar Therapy
• Mannitol
– Osmotic diuretic
– Can cause hypotension
– Fairly quick onset
• Hypertonic saline
– Osmotic diuretic
– Does not cause hypotension
– May increase CPP
Phenobarbital Coma
• Not done anymore at HCMC
– Supplanted by iatrogenic hypothermia
• Requires intensive monitoring
• Downsides to Phenobarbital
– Pneumonia
– Feeding intolerance
– Cardiac depression
• Hypotension from phenobarbital erases any
beneficial effect
Hypothermia
• Current practice at HCMC
• Better outcomes in most RCTs
examining hypothermia
– Mixed results regarding mortality
• None showing worse mortality
• Some showing improved mortality
– All RCTs report improved GOS (Glasgow
Outcome Scale) in those treated with
hypothermia
Decompressive crainectomy
• Neurosurgical decision
• Violates the Monro-Kellie Doctrine
Anti-Seizure Prophylaxis
• Post Traumatic Seizures (PTS)
– Early < 7 days
– Late > 7 days
• No evidence that routine prophylaxis
decreases late seizures
• Anti-seizure prophylaxis effective in
early seizures
Anti-Seizure Prophylaxis
• Indications for treatment
– GCS < 10
– Cortical contusion
– Depressed skull fracture
– Subdural hematoma
– Intracerebral hematoma
– Penetrating head wound
– Seizure within 24 h of injury
Steroids
• Only level I data from the Brain Trauma
Foundation Guidelines is don’t use
steroids
General Critical Care
Concepts
Ventilatory Management
• Most significant head injuries get intubated at
some point for airway protection
• Some are on significant sedation to impact
their ICP
• Most weaning protocols end with the
assessment of the patient’s ability to follow
commands
• Therefore many are on ventilators for some
time
Ventilatory Management
• Most head injured patients have normal
lungs
– They don’t all stay that way
Ventilatory Management
Infection prevention/treatment
•
•
•
•
VAP prevention
Catheter infection prevention
Urinary catheter infection prevention
Fever work ups
– Five W’s
•
•
•
•
•
Wind
Water
Wounds
Walking
Wonder Drugs
Nutrition
VTE Prophylaxis
• VTE= VenoThromboEmbolism
• Risk of developing DVT in severe brain
injury about 20%
• Best treatment is prevention
• No good data on timing
– DEEP study out of Parkland
• IVC Filters
Other conditions
• Head injured patients are already
complicated
– Adding other injuries adds to the
complexity
• Gatekeeper
Ethics
• Family discussions
• Difficult to predict level of long term
impairment sometimes
• There can be fates worse than death
• Comfort Care
Case Presentation #1
• Fixed and dilated pupils
• + Corneals and gag reflexes
• Withdraws upper extremities, flexion
posturing lower extremities
• Intensive family discussions
• Comfort care
Case Presentation #2
• Localized to pain on arrival
• Ventriculostomy placed
• ICPs high
– All efforts employed including cooling
• Cooled for about a week
• Neurologic exam worsened on warming
on HD#17
Case Presentation #2
Case Presentation #2
Conclusions
• The Trauma Surgeon/Surgical
Intensivist plays a core role in the care
of the acute brain injured patient
Questions?