Traumatic Brain Injury Traumatic Brain Injury Management- What Really Management- What Really Happened to the ScarecrowHappened to the Scarecrow

Glenn Carlson APRN MSN CCRNCritical Care Clinical Nurse Specialist

Bronson Methodist HospitalKalamazoo MI

TBI case reviewTBI case review

I have no conflict of interest with any of the information presented in this review Glenn Carlson APRN MSN CCRN

I am on the AACN speakerrsquos bureau

Dorothy and tornadoDorothy and tornado

httpwwwyoutubecomwatchv=5xNA8seaqGQampfeature=related

TBI case reviewTBI case review

I have no conflict of interest with any of the information presented in this review Glenn Carlson APRN MSN CCRN

I am on the AACN speakerrsquos bureau

Dorothy and tornadoDorothy and tornado

httpwwwyoutubecomwatchv=5xNA8seaqGQampfeature=related

Dorothy and tornadoDorothy and tornado

httpwwwyoutubecomwatchv=5xNA8seaqGQampfeature=related

Dorothy meets scarecrowDorothy meets scarecrow

httpwwwyoutubecomwatchv=wKrJoih_uCQ

Case 1Case 1

Case 2Case 2

Egypt- Lessons from warEgypt- Lessons from war

A doctor would first carefully lift larger broken pieces of skull off of the brain and then any small fragments would be brushed away and discarded The larger pieces would be carefully replaced onto the brain and a disinfectant made of warm wine and rose oil (they didnrsquot know it killed germs because they did not yet understand the germ theory) was put against the outer membrane of the brain At last the patientrsquos head would be wrapped in bandages eventually many would heal This along with twenty-six other techniques for treating head injuries is described in the Smithrsquos Papyrus

FYI- part of series on FYI- part of series on

The Papyrus was on display at the Met from September 13 2005 through January 15 2006

Case 2Case 2

Egypt- Lessons from warEgypt- Lessons from war

A doctor would first carefully lift larger broken pieces of skull off of the brain and then any small fragments would be brushed away and discarded The larger pieces would be carefully replaced onto the brain and a disinfectant made of warm wine and rose oil (they didnrsquot know it killed germs because they did not yet understand the germ theory) was put against the outer membrane of the brain At last the patientrsquos head would be wrapped in bandages eventually many would heal This along with twenty-six other techniques for treating head injuries is described in the Smithrsquos Papyrus

FYI- part of series on FYI- part of series on

The Papyrus was on display at the Met from September 13 2005 through January 15 2006

Egypt- Lessons from warEgypt- Lessons from war

A doctor would first carefully lift larger broken pieces of skull off of the brain and then any small fragments would be brushed away and discarded The larger pieces would be carefully replaced onto the brain and a disinfectant made of warm wine and rose oil (they didnrsquot know it killed germs because they did not yet understand the germ theory) was put against the outer membrane of the brain At last the patientrsquos head would be wrapped in bandages eventually many would heal This along with twenty-six other techniques for treating head injuries is described in the Smithrsquos Papyrus

FYI- part of series on FYI- part of series on

The Papyrus was on display at the Met from September 13 2005 through January 15 2006

FYI- part of series on FYI- part of series on

The Papyrus was on display at the Met from September 13 2005 through January 15 2006

TrephiningTrephining

Used to relieve pressure

Used to let out demons

Australian doctor uses household drill Australian doctor uses household drill to save boy- May 20 2009to save boy- May 20 2009

MELBOURNE Australia ndash A doctor in rural Australia used a handymans power drill to bore a hole into the skull of a boy with a severe head injury saving his lifeNicholas Rossi fell off his bike on Friday in the small Victoria state city of Maryborough hitting his head on the pavement his father Michael said Wednesday By the time Rossi got to the hospital he was slipping in and out of consciousnessThe doctor on duty Rob Carson quickly recognized the boy was experiencing potentially fatal bleeding on the brain and knew he had only minutes to make a hole in the boys skull to relieve the pressureBut the small hospital was not equipped with neurological drills mdash so Carson sent for a household drill from the maintenance roomDr Carson came over to us and said I am going to have to drill into (Nicholas) to relieve the pressure on the brain mdash weve got one shot at this and one shot only Michael Rossi told The Australian newspaperCarson called a neurosurgeon in the state capital of Melbourne for help who talked Carson through the procedure mdash which he had never before attempted mdash by telling him where to aim the drill and how deep to goAll of a sudden the emergency ward was turned into an operating theater Michael Rossi told Fairfax Radio on Wednesday We didnt see anything but we heard the noises heard the drill It was just one of those surreal experiences

Brain Injury managementBrain Injury management

Hyperventilation Steroids Dehydration Craniectomy

Chest 2005 May127(5)1812-27 Stocchetti N Maas AI Chieregato A van der Plas AA

Primer on medical management of severe brain injuryJean-Louis Vincent MD PhD FCCM Jacques Berreacute MDCrit Care Med 2005 331392ndash1399

Australian doctor uses household drill Australian doctor uses household drill to save boy- May 20 2009to save boy- May 20 2009

MELBOURNE Australia ndash A doctor in rural Australia used a handymans power drill to bore a hole into the skull of a boy with a severe head injury saving his lifeNicholas Rossi fell off his bike on Friday in the small Victoria state city of Maryborough hitting his head on the pavement his father Michael said Wednesday By the time Rossi got to the hospital he was slipping in and out of consciousnessThe doctor on duty Rob Carson quickly recognized the boy was experiencing potentially fatal bleeding on the brain and knew he had only minutes to make a hole in the boys skull to relieve the pressureBut the small hospital was not equipped with neurological drills mdash so Carson sent for a household drill from the maintenance roomDr Carson came over to us and said I am going to have to drill into (Nicholas) to relieve the pressure on the brain mdash weve got one shot at this and one shot only Michael Rossi told The Australian newspaperCarson called a neurosurgeon in the state capital of Melbourne for help who talked Carson through the procedure mdash which he had never before attempted mdash by telling him where to aim the drill and how deep to goAll of a sudden the emergency ward was turned into an operating theater Michael Rossi told Fairfax Radio on Wednesday We didnt see anything but we heard the noises heard the drill It was just one of those surreal experiences

Brain Injury managementBrain Injury management

Hyperventilation Steroids Dehydration Craniectomy

Chest 2005 May127(5)1812-27 Stocchetti N Maas AI Chieregato A van der Plas AA

Primer on medical management of severe brain injuryJean-Louis Vincent MD PhD FCCM Jacques Berreacute MDCrit Care Med 2005 331392ndash1399

Brain Injury managementBrain Injury management

Hyperventilation Steroids Dehydration Craniectomy

Chest 2005 May127(5)1812-27 Stocchetti N Maas AI Chieregato A van der Plas AA

Primer on medical management of severe brain injuryJean-Louis Vincent MD PhD FCCM Jacques Berreacute MDCrit Care Med 2005 331392ndash1399

Hyperventilation- goal is to Hyperventilation- goal is to keep PCO2 at 35 keep PCO2 at 35

Theory is decreased CO2 causes vasoconstriction and decreased ICP Rebound intracranial hypertension may occur Vasoconstriction decreases flow in the TBI patient who

already may have impaired CBF by up to 50 rt the TBI

May promote cellular anaerobic metabolism and a shift in the oxyhemoglobin curve- less oxygen release from the blood (theory)

Moderate CO2 reduction for short periods may be beneficial (28-35 never less than 25)

Long periods of CO2 reduction has been shown to increase mortality in the TBI patient Critical Care Medicine Volume 25(8) August 1997 pp 1402-1409

Effect of hyperventilation on regional cerebral blood flow in head-injured childrenSkippen Peter FANZCA Seear Michael FRCP Poskitt Ken FRCP Kestle John FRCSC Cochrane

Doug FRCSC Annich Gail FRCP Handel Jeffrey MRCP

Steroids- Crash TrialSteroids- Crash Trial

Although beneficial in reducing edema associated with brain tumor not recommended for brain injury No change in outcome and increased potential for infection Crash trial (Corticosteroid randomization after significant head injury) reported in Lancet 2004 Patient who received steroids had a greater 2 week mortality

DehydrationDehydration

No longer drying out patients Maintain euvolemic state Arterial

hypotension in trauma most of the time indicates hypovolemia

Volume is indicated when cerebral blood flow (oxygenation) is low and CPP low (less than 60)

Too much fluid can cause ARDS

Craniectomy Craniectomy

Early (within 24 hours) versus late within 48 hours) upper ICP limit Early has been show to have some benefit especially for patients with ICP lt 40mmHg

Unilateral frontotemporoparietal bone flap vs temporoparietal bone flap Article in Neurotrauma suggests that unilateral frontotemporalparietal bone flap provides better outcome in patients with refractory intracranial hypertension

Initial gift of $350000 with additional $350000 in 2004 was funded by a former patientrsquos family (Williams)

Support was used to bring the BTF (Brain Trauma Foundation) Guidelines and Technology used to manage TBI patients to twenty trauma centers in US Bronson applied and was selected as one of the twenty trauma centers in 2004 to begin the initiative in 2005

Steroids- Crash TrialSteroids- Crash Trial

Although beneficial in reducing edema associated with brain tumor not recommended for brain injury No change in outcome and increased potential for infection Crash trial (Corticosteroid randomization after significant head injury) reported in Lancet 2004 Patient who received steroids had a greater 2 week mortality

DehydrationDehydration

No longer drying out patients Maintain euvolemic state Arterial

hypotension in trauma most of the time indicates hypovolemia

Volume is indicated when cerebral blood flow (oxygenation) is low and CPP low (less than 60)

Too much fluid can cause ARDS

Craniectomy Craniectomy

Early (within 24 hours) versus late within 48 hours) upper ICP limit Early has been show to have some benefit especially for patients with ICP lt 40mmHg

Unilateral frontotemporoparietal bone flap vs temporoparietal bone flap Article in Neurotrauma suggests that unilateral frontotemporalparietal bone flap provides better outcome in patients with refractory intracranial hypertension

Initial gift of $350000 with additional $350000 in 2004 was funded by a former patientrsquos family (Williams)

Support was used to bring the BTF (Brain Trauma Foundation) Guidelines and Technology used to manage TBI patients to twenty trauma centers in US Bronson applied and was selected as one of the twenty trauma centers in 2004 to begin the initiative in 2005

DehydrationDehydration

No longer drying out patients Maintain euvolemic state Arterial

hypotension in trauma most of the time indicates hypovolemia

Volume is indicated when cerebral blood flow (oxygenation) is low and CPP low (less than 60)

Too much fluid can cause ARDS

Craniectomy Craniectomy

Early (within 24 hours) versus late within 48 hours) upper ICP limit Early has been show to have some benefit especially for patients with ICP lt 40mmHg

Unilateral frontotemporoparietal bone flap vs temporoparietal bone flap Article in Neurotrauma suggests that unilateral frontotemporalparietal bone flap provides better outcome in patients with refractory intracranial hypertension

Initial gift of $350000 with additional $350000 in 2004 was funded by a former patientrsquos family (Williams)

Support was used to bring the BTF (Brain Trauma Foundation) Guidelines and Technology used to manage TBI patients to twenty trauma centers in US Bronson applied and was selected as one of the twenty trauma centers in 2004 to begin the initiative in 2005

Craniectomy Craniectomy

Early (within 24 hours) versus late within 48 hours) upper ICP limit Early has been show to have some benefit especially for patients with ICP lt 40mmHg

Unilateral frontotemporoparietal bone flap vs temporoparietal bone flap Article in Neurotrauma suggests that unilateral frontotemporalparietal bone flap provides better outcome in patients with refractory intracranial hypertension

Initial gift of $350000 with additional $350000 in 2004 was funded by a former patientrsquos family (Williams)

Support was used to bring the BTF (Brain Trauma Foundation) Guidelines and Technology used to manage TBI patients to twenty trauma centers in US Bronson applied and was selected as one of the twenty trauma centers in 2004 to begin the initiative in 2005

Initial gift of $350000 with additional $350000 in 2004 was funded by a former patientrsquos family (Williams)

Support was used to bring the BTF (Brain Trauma Foundation) Guidelines and Technology used to manage TBI patients to twenty trauma centers in US Bronson applied and was selected as one of the twenty trauma centers in 2004 to begin the initiative in 2005

What is itWhat is it

Analysis of AANS (American Association of Neurologic Surgeons) TBI guidelines

ndashAvoid hypotensionhypoxia ndashMaintain MAP gt 90 mm Hg ndashMaintain CPP gt 70 mm Hg ndashTreat ICP gt 20 mm Hg ndashAvoid hyperventilation in severe TBI unless cerebral oxygenation

is monitored ndashUse intermittent mannitol with replacement of fluids to maintain

euvolemia ndashUse barbiturates for uncontrollable ICP ndashUse craniectomy for uncontrollable ICP ndashEstablish a critical pathwayalgorithm ndashIncrease MAP with albumin and vasopressors ndashDecrease environmental stimulation ndashUse sedation and analgesia in continuous modes ndashTreat fever aggressively ndashDevelop targeted therapy algorithms for specific clinical situations ndashIncorporate a weaning algorithm

Brain monitoring earlyBrain monitoring early

Multimodal monitoringMultimodal monitoring

Cerebral oxygenation + ICP measurement + CSF drainage Via one access device or two

SJO2

Cerebral oxygenation via LicoxCerebral oxygenation via Licox

July TBI case reviewJuly TBI case review

Case review

July TBI case reviewJuly TBI case review

Teenage male passenger involved in high energy car versus train

Left subdural hematoma (4mm) with 7 mm midline shift

C4 endplate (VB compression) fx- Aspen Left pulmonary contusion with pneumothorax Grade I liver laceration Left humerous midshaft fx ORIF Multiple scalp laceration and an avulsed chin

multiple other laceration and a thumb tendon tear

Continued reviewContinued review

Patient admitted to SICU around 1000 am Lacerations to chin head elbow thumb repaired Awaiting Dr England to come from the OR Pupillometer in ED Cv of 128136 (rl)

LiCox place at 1554 (about 10 hours after arrival)

Opening Pbto2 of 62 ICP 20 CPP 59 CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac)

At 1900 PbTO2 remains less than 15 CPP 55 ICP 15 CVP 5 despite 500 cc albumin and 125 ugmin Neo

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Brain monitoring earlyBrain monitoring early

Multimodal monitoringMultimodal monitoring

Cerebral oxygenation + ICP measurement + CSF drainage Via one access device or two

SJO2

Cerebral oxygenation via LicoxCerebral oxygenation via Licox

July TBI case reviewJuly TBI case review

Case review

July TBI case reviewJuly TBI case review

Teenage male passenger involved in high energy car versus train

Left subdural hematoma (4mm) with 7 mm midline shift

C4 endplate (VB compression) fx- Aspen Left pulmonary contusion with pneumothorax Grade I liver laceration Left humerous midshaft fx ORIF Multiple scalp laceration and an avulsed chin

multiple other laceration and a thumb tendon tear

Continued reviewContinued review

Patient admitted to SICU around 1000 am Lacerations to chin head elbow thumb repaired Awaiting Dr England to come from the OR Pupillometer in ED Cv of 128136 (rl)

LiCox place at 1554 (about 10 hours after arrival)

Opening Pbto2 of 62 ICP 20 CPP 59 CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac)

At 1900 PbTO2 remains less than 15 CPP 55 ICP 15 CVP 5 despite 500 cc albumin and 125 ugmin Neo

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Multimodal monitoringMultimodal monitoring

Cerebral oxygenation + ICP measurement + CSF drainage Via one access device or two

SJO2

Cerebral oxygenation via LicoxCerebral oxygenation via Licox

July TBI case reviewJuly TBI case review

Case review

July TBI case reviewJuly TBI case review

Teenage male passenger involved in high energy car versus train

Left subdural hematoma (4mm) with 7 mm midline shift

C4 endplate (VB compression) fx- Aspen Left pulmonary contusion with pneumothorax Grade I liver laceration Left humerous midshaft fx ORIF Multiple scalp laceration and an avulsed chin

multiple other laceration and a thumb tendon tear

Continued reviewContinued review

Patient admitted to SICU around 1000 am Lacerations to chin head elbow thumb repaired Awaiting Dr England to come from the OR Pupillometer in ED Cv of 128136 (rl)

LiCox place at 1554 (about 10 hours after arrival)

Opening Pbto2 of 62 ICP 20 CPP 59 CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac)

At 1900 PbTO2 remains less than 15 CPP 55 ICP 15 CVP 5 despite 500 cc albumin and 125 ugmin Neo

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Cerebral oxygenation via LicoxCerebral oxygenation via Licox

July TBI case reviewJuly TBI case review

Case review

July TBI case reviewJuly TBI case review

Teenage male passenger involved in high energy car versus train

Left subdural hematoma (4mm) with 7 mm midline shift

C4 endplate (VB compression) fx- Aspen Left pulmonary contusion with pneumothorax Grade I liver laceration Left humerous midshaft fx ORIF Multiple scalp laceration and an avulsed chin

multiple other laceration and a thumb tendon tear

Continued reviewContinued review

Patient admitted to SICU around 1000 am Lacerations to chin head elbow thumb repaired Awaiting Dr England to come from the OR Pupillometer in ED Cv of 128136 (rl)

LiCox place at 1554 (about 10 hours after arrival)

Opening Pbto2 of 62 ICP 20 CPP 59 CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac)

At 1900 PbTO2 remains less than 15 CPP 55 ICP 15 CVP 5 despite 500 cc albumin and 125 ugmin Neo

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

July TBI case reviewJuly TBI case review

Case review

July TBI case reviewJuly TBI case review

Teenage male passenger involved in high energy car versus train

Left subdural hematoma (4mm) with 7 mm midline shift

C4 endplate (VB compression) fx- Aspen Left pulmonary contusion with pneumothorax Grade I liver laceration Left humerous midshaft fx ORIF Multiple scalp laceration and an avulsed chin

multiple other laceration and a thumb tendon tear

Continued reviewContinued review

Patient admitted to SICU around 1000 am Lacerations to chin head elbow thumb repaired Awaiting Dr England to come from the OR Pupillometer in ED Cv of 128136 (rl)

LiCox place at 1554 (about 10 hours after arrival)

Opening Pbto2 of 62 ICP 20 CPP 59 CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac)

At 1900 PbTO2 remains less than 15 CPP 55 ICP 15 CVP 5 despite 500 cc albumin and 125 ugmin Neo

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

July TBI case reviewJuly TBI case review

Teenage male passenger involved in high energy car versus train

Left subdural hematoma (4mm) with 7 mm midline shift

C4 endplate (VB compression) fx- Aspen Left pulmonary contusion with pneumothorax Grade I liver laceration Left humerous midshaft fx ORIF Multiple scalp laceration and an avulsed chin

multiple other laceration and a thumb tendon tear

Continued reviewContinued review

Patient admitted to SICU around 1000 am Lacerations to chin head elbow thumb repaired Awaiting Dr England to come from the OR Pupillometer in ED Cv of 128136 (rl)

LiCox place at 1554 (about 10 hours after arrival)

Opening Pbto2 of 62 ICP 20 CPP 59 CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac)

At 1900 PbTO2 remains less than 15 CPP 55 ICP 15 CVP 5 despite 500 cc albumin and 125 ugmin Neo

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Continued reviewContinued review

Patient admitted to SICU around 1000 am Lacerations to chin head elbow thumb repaired Awaiting Dr England to come from the OR Pupillometer in ED Cv of 128136 (rl)

LiCox place at 1554 (about 10 hours after arrival)

Opening Pbto2 of 62 ICP 20 CPP 59 CVP 2 (lost a lot of fluid due to scalp laceration and had some fluid in pelvis presumably from liver lac)

At 1900 PbTO2 remains less than 15 CPP 55 ICP 15 CVP 5 despite 500 cc albumin and 125 ugmin Neo

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Continue Day 1Continue Day 1

2 units of blood (HCT 327) ordered and PbtO2 responds t0 268 by 2000 before 1st unit completed CVP 8 CPP 82 ICP 14 Neo at 135 ugmin

By the time the second unit of blood is infusing- 2100 the PbtO2 is now 40 Neo down to 125 ugmin CPP 79 ICP 8 CVP 8

End tidal CO2 37-41 actually increased CO2 to increase PbtO2 at 1900 and ICP 13 to 15

BIS mostly in 50-60

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Continued Day 1Continued Day 1

Coughing fit at 2200 caused temporary elevation in ICP and PbtO2 to decrease to 11 Propofol increased 100 oxygen morphine bolus (patient moving all extremities at this time)

By 2300 and draining 10 cc CSF- PbtO2 23 ICP down from 35 to 13 During this time patient ETCO2 46-51 (bronchospasm)

First 8 hours of LiCox- 500 albumin and 2 units of cells fluid requirements

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Day 2Day 2

PbtO2 14 for 4 minutes when ICP gt23 CSF drained 100 oxygen otherwise in the mid 20s to 30s and as high as 47 (this occurred after CSF drainage for increased ICP and 100 oxygen flush)

CSF drainage worked well to keep ICP lt 20 Oxygen weaned to 50 by 1000 and Neo to 80

ugmin 1L albumin additional fluid for Day 2 (However

remember no Mannitol given as CSF drainage worked well to decrease ICP for 1st 2 days

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Day 3Day 3

40 oxygen Neo at 65ugmin placed on sport bed

Additional 750 of albumin PbtO2 mid 20s and 30s gradual

increasing EtCO2 with minimal effect on ICP When ICP increased CSF drained and an occasional propofol bolus

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Day 4Day 4

PbtO2 without any big drops ICP elevations for total of 90 minutes throughout day did get Mannitol x 1 and CSF drainage done When PbtO2 drifted down blood administered and remained in the 30s

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Day 5Day 5

LiCoxVentric discontinued Patient attempting to open eyes Neuro status waxing and waning

Morphine and Ativan prematurely discontinued and restarted Day 5 night

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Rest of stayRest of stay

Extubated on Day 9 BVH on Day 16 Discharged to home from BVH after 9

days with remarkable improvement Independent ADLs Continent Memory improving Walking 200 feet without assistance Amnesia lessening Problem solving improving although

abstract thoughts and complex math remains difficult

Socially interactive

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Case 1Case 1

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Case 1- video playCase 1- video play

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Case 2Case 2

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Case 2 More PicsCase 2 More Pics

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Case 2 VideosCase 2 Videos

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Lessons learnedLessons learned

It does work- grave prognosis to survival and continued progress towards independence

Fluid required despite not using mannitol- not just a brain injury Think scalp laceration blood

loss Other injury blood loss Lactate is your friend If Hct gt 33 upon arrival

recheck in 4 hours after resus at Hct may have been hemoconcentrated

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Net fluid by days- would Net fluid by days- would need more if Mannitol usedneed more if Mannitol used

1 +9002 +19003 +15004 +25005 +22006 -2007 -13008 -2800

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

More lessonsMore lessons

DO NOT STOP ANALGESIA OR ANXIOLYSIS SLOW WEAN

CO2 can be your friend VAP probability 327- no VAP HOB

elevation and early rotational therapy vs luck (called a tracheobronchitis)

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

ICP management- ICP management- something newsomething new

CRRT and Intracranial hypertension

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7 [Epub ahead of print]

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

INTRODUCTION Little is known about the effects of hemodialysis on the injured brain however concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety Furthermore exacerbations of cerebral edema have been reported CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma He required significant volume resuscitation Intensive care unit course was complicated by shock acute respiratory distress syndrome ventilator associated pneumonia and development of intracranial hypertension (IH) Data were collected by retrospective chart review RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy Within hours of initiation increase ICP improved and normalized Hemofiltration was safely discontinued after 48 h Modified Rankin Score was 2 at 90 days CONCLUSION Though unproven CRRT may be beneficial in patients with IH due to gentle removal of fluid solutes and inflammatory cytokines Given the limited data on safety of CRRT in patients with ABI we encourage further reports

Fletcher JJ Bergman K Feucht EC Blostein PNeurocrit Care 2009 Mar 7

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

How does it workHow does it work

Diuretics cause electrolyte imbalance and perfusion dynamics that may cause harm

CRRT removes free water and may remove cardiac inhibitory factors

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

IndicationsIndications

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

Resource for familiesResource for families

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions

QuestionsQuestions

• Traumatic Brain Injury Management- What Really Happened to the Scarecrow
• TBI case review
• Dorothy and tornado
• Dorothy meets scarecrow
• Case 1
• Case 2
• Egypt- Lessons from war
• FYI- part of series on
• Trephining
• Australian doctor uses household drill to save boy- May 20 2009
• Brain Injury management
• Hyperventilation- goal is to keep PCO2 at 35
• Steroids- Crash Trial
• Dehydration
• Craniectomy
• PowerPoint Presentation
• What is it
• Brain monitoring early
• Multimodal monitoring
• Cerebral oxygenation via Licox
• Slide 21
• Slide 22
• July TBI case review
• Slide 24
• Continued review
• Continue Day 1
• Continued Day 1
• Day 2
• Day 3
• Day 4
• Day 5
• Rest of stay
• Slide 33
• Case 1- video play
• Slide 35
• Case 2 More Pics
• Case 2 Videos
• Lessons learned
• Net fluid by days- would need more if Mannitol used
• More lessons
• ICP management- something new
• Slide 42
• Slide 43
• Fletcher JJ Bergman K Feucht EC Blostein P Neurocrit Care 2009 Mar 7
• How does it work
• Indications
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Resource for families
• Questions