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Twyila Lay MS, ACNP-BC Brain and Spinal Injury Center

Unraveling the Mysteries of Traumatic Brain Injury

Who? What? When? Where? Why?

  73 year old female with a history of atrial fibrillation on Coumadin. S/P mechanical fall down three steps. (+) LOC, (+) Post-traumatic amnesia, no witnessed seizure activity

  GCS in the field 9: E1, V2, M4

  ETA to hospital 10 minutes

Glasgow Coma Scale

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Teasdale & Jennett Glasgow University 1974

  On presentation ◦  GCS 3 with bilateral fixed and dilated pupils (6mm) ◦  Absent Corneals ◦  Weak Gag

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  70% Head Injured Patients Experience a Hypoxic Insult

  Vitals ◦  HR: 50 ◦  Blood Pressure: 210/105

  Signs of Cushings Triad ◦  Hypertension   Widening Pulse Pressure   Vasomotor Center ◦  Bradycardia   Cardiac Center ◦  Tachypnea   Respiratory Center

Cushings Response

  Mannitol administered per the Severe Traumatic Brain Injury Guidelines with a return of bilateral pupillary reflexes

  With the administration of mannitol her pupillary response returned, and the patient was deemed a surgical candidate.

  Patient’s INR: 2.4 ◦  Seven to Ten fold higher risk for development of

Intracranial Hemorrhage ◦  Increased Risks in Setting of Trauma   Increased Morbidity and Mortality   Hematoma Expansion

  Indications ◦  INR due to Warfarin Action ◦  Hemorrhage judged as acutely life, limb or sight threatening ◦  INR >1.5 or clinical evidence the pt is on Warfarin

  Contraindications ◦  Uncontrolled Bleeding

  Dose ◦  50 international units x Pt wt in Kg ◦  Round up/down to nearest full vial

  Administration ◦  Give over 10 minutes

  Onset of Action ◦  10 minutes

  Duration of Action ◦  24 hours

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  Compatibility ◦  Ok to infuse with blood products

  Mechanism of Action ◦  Intrinsic pathway of coagulation cascade

  Treatment Orders ◦  Bebulin x 1 Dose ◦  DC Warfarin ◦  Vitamin K 10mg IV x 1 dose ◦  FFP x 2 Units

  Adverse Reactions ◦  Thrombosis (VTE) ◦  Microvascular complications (lung injury, renal failure)

  How Do I Get the Drug ◦  Order form on CHN intranet ◦  Phone to pharmacy “order is coming” ◦  Fax order to pharmacy ◦  Follow up with pharmacy!!! ◦  Send someone to pick up the drug in 20 minutes

  Cost ◦  $3000.00/vial

  Taken to emergently to the operating room for a right sided decompressive hemicraniectomy

  Kocher and Cushing first introduced cranial decompression for intracranial hypertension around the turn of the 19th century

  Decompression decreases ICP, improves cerebral oxygenation, and improves CBF

  Timing of Decompression ◦  Decompress and evacuate early if there is a

lesion causing obvious mass effect

◦  Consider your therapeutic intensity when considering timing of decompression

  SDH with a thickness >10mm or MLS >5mm regardless of GCS

  ALL patients with a SDH and a GCS <9 should have ICP monitoring

  GCS <9 with a SDH <10mm in thickness and MLS <5mm should undergo evacuation, if the GCS declines between the time of injury and admit by >2 points and/or the ICP is >20 mm Hg

  Parenchymal mass lesion and signs of progressive neurologic deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on CT should be treated operatively

  GCS 6-8 with frontal or temporal contusions >20cc in volume with MLS >5mm and/or cistern compression on CT scan should be treated operatively

  Any lesion >50cc in volume should be treated operatively

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15cm

10cm

“ Go Big or Go Home”

What Happens in the Operating Room?

Risk of infection: 6-8%

  Leave incision open to air

  Clean surgical site with Normal saline Q12 hours

  Bacitracin for the first 72 hours

  Keep patient positioned off surgical wound at ALL TIMES

  Notify the service ASAP for the following signs of infection

  Redness or Swelling   Drainage   Fever   Elevated WBC

  Ensure Good Nutrition and Hygiene Practices   Daily Showers and Gentle Hair Washing

  Wound Healing Vitamins ◦  Vitamin A, C, Zinc

 Treatment According to Guidelines

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  VTE Prophylaxis was Started

  Options ◦  SCDS (Everyone Should Get These!!) ◦  Pharmaceutical Anticoagulation   Lovenox 40mg SQ QD   Heparin 5000units SQ Q8

  Timing ◦  Patient Dependent

  The patient was loaded with Dilantin

  Prophylactic Dosing was Inititiated

  Who should get prophylaxis? ◦  Patient’s with GCS <10 ◦  Patient’s with

  Parenchymal cotusion(s)   SDH   EDH   depressed skull fracture > skull thickness   penetrating head trauma   seizure within 24 hours of injury

Administer for 7 days unless evidence of

seizure activity

  Therapeutic Levels: 10-20mcg/ml ◦  Dilantin (DPH) is highly bound to plasma proteins   Albumin (90%)

  Side Effects of Dilantin Administration ◦  Hypotension, Bradycardia, and EKG Changes ◦  Severe Thrombophlebitis (Purple Glove Syndrome ◦  CNS depression (nystagmus, somnolence, ataxia

Serum DPH [(0.2 x alb) + 0.1] [DPH] =

  *Hypotension (IV) ◦  Administer <25mg/min ◦  Consider fosphenytoin

  Skin Necrosis (IV) ◦  Use small gauge needle in large vein ◦  Avoid IV’s in joints ◦  Avoid IV’s >24 hours old ◦  Consider injection of hyaluronidase

  Hypersensitivity (IV & PO) ◦  Rash

  Blood Dyscrasias (IV & PO)

  Food Interations (PO)

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  Occur in 35% of all TBI patients

  A single episode of hypotension in TBI leads to a Two-Fold increase in Mortality

  Three episodes of hypotension leads to a Eight-Fold increase in Mortality

◦  Hypotentison: Systolic blood pressure <90mmHg

  Post-operative the patient was taken to the ICU and an Intracranial pressure monitor was placed

Why Measure Intracranial Pressure?

ICP Predicts Outcome

 Beyond age and neuro exam, the amount of time ICP > 20 mm Hg is most predictive of outcome

  ICP should be monitored in all patients with: ◦  severe TBI (GCS 3-8 after resuscitation) AND ◦  an abnormal CT scan both on admission and on

repeat.

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  Patients with severe TBI (GCS 3-8) and a Normal CT scan if 2 or more of the following features are noted upon admission:

  age > 40   unilateral or bilateral motor posturing   SBP < 90 mm Hg

  A combination of ICP values and clinical and brain CT findings should be used to determine the need for treatment

  ICP > 20 mm Hg Is it Enough?

Case Study: Multimodal Neuromonitoring for TBI

SjvO2 CBF

PbtO2

EVD

CVP

CBF

EVD

PbtO2

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CBF

EVD

Licox

Monitor Placement

  Complimentary information

◦  Local Monitors   Brain tissue oxygenation   CBF

◦  Hemispheric Monitors   SjvO2

PbtO2

CBF SjvO2

Stop Secondary Brain Injury!!!!

  Systemic Insults  Hypoxia  Hypotension  Hyper/Hypocapnia   Increase Intracranial Pressure  Anemia  Hyper/Hypoglycemia  Acid base disturbances

CBF Brain Tissue Oxygen

  Early Detection low PaO2

  Tailor CPP management

  Optimize Hyperventilation

  Early Detection of Imminent ICP Elevation

PbtO2

  By POD#4 all the patient’s monitors were able to be discontinued and she was successfully transferred to the floor

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  No monitoring available ◦  Emphasis on following trends

  Neurological exam   GCS

  Transition 1:1 nursing to a nurse ratio of 1:4 ◦  Patient and Family Expectations

  Agitation & Patient Frustration with Recovery

  Changes in Medication Regimen ◦  Narcotic Wean

  Often rapid wean when transferring from ICU to floor   Expected Wean 10% per Day

  Enhanced Communication

  Stimulation Control ◦  Balance between sensory overload and deprivation

  Environmental Modifications ◦  **Key

  Rancho Los Amigos Scale ◦  Awareness of current stage in the recovery process ◦  Turn to your “COWS”

  Pt is increasingly agitated

  Sweating

  HR increased to 130

  BP 160/90

  Febrile 39.2°C

  M: Metabolic   O: Oxygenation   V: Vascular   E: Endocrine/Electrolytes/Environment   S: Seizures   T: Trauma/Tumor/Temperature   U: Uremia   P: Psychiatric   I: Infection   D: Drugs

 Labs return with Sodium Level of 129Meq/L

Na+

  Normal Sodium: 134-145mEq/L   Most likely to Occur in Patient’s with Large

Contusions   Symptoms ◦  Confusion ◦  Agitation ◦  Seizures ◦  Coma

  Diagnosis ◦  Assess Volume Status ◦  Urine Output ◦  Labs

  Uosmo   Sosmo   Chem 7

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CSW (salt loss)

Volume Depletion

Volume Expanded

SNa+ <135 Sosmo <280

Una+ >20mEq/L

SIADH (H2O retention)

Fluid Replacement +

Salt Tabs Fluid

Restriction

 Failure to distinguish CSW from SIADH in a hyponatremic patient with a brain injury will lead to inappropriate therapy and potentially exacerbate morbidity and mortality

  Monitor Intake and Output

  Replacement of both fluids and sodium ◦  Hydration with Normal Saline ◦  Na+ replacement   First line is 3% @ 20-90 cc/hr   NaCl 3gms Q6-8   Florinef 0.1-0.2mg PO Daily

  Follow serum sodiums closely

  Pt is obtunded GCS 12 now 8

  What are your concerns and interventions?

  What are your Priorities?

  Respiratory insult ◦  Infection, PE, Hypoventilation

  Infection ◦  Hypotension, Fever, Sepsis

  Toxic Metabolic ◦  Hyponatremia

  Seizures

  Hydrocephalus   New Bleed ◦  Head CT

  Apply O2 via Face Mask

  Position on side to prevent aspiration

  DO NOT try to insert and airway

  Establish an IV, Prepare to administer benzodiazepines and anti-epileptic medications

  Ensure patient safety

  Institute seizure precautions

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  Formal Presentation at Interdisciplinary Team Rounds (IDT) ◦  Neurosurgery ◦  Social Work ◦  Rehab Services (PT,OT, ST, PM&R) ◦  Nutrition ◦  Eligibility ◦  Utilization Review ◦  Neurotrauma Outreach ◦  Neuropsychology ◦  Clinical Nurse Specialist ◦  Nursing

  The patient was considered to be medically stable and ready for Discharge

  Acute Rehabilitation ◦  Follows 90% of Commands Consistently ◦  Tolerate 2-3 hours of combined rehabilitation a day ◦  Must require Physical therapy and one other rehab

discipline ◦  Average Stay 2-3 weeks

  Skilled Nursing Facility Rehabilitation ◦  Follows 75% of commands ◦  Tolerate 1-2hours of combined rehab in one day ◦  Average Stay <2 months

  Long-Term Skilled Nursing Facility ◦  Require Care >2 months

◦  Skilled needs for this level of care include   Feeding Tube   Rehabilitation Services

  Patients can receive rehabilitation services at this level if they are actively participating and making gains

◦  A patient becomes "custodial" when they don't have any skilled needs but require twenty-four hour care and can't go back to the community   Patients can stay in this level of care for their lifetimes

  Subacute Care ◦  This level of care is for patients who are on a

ventilator or have a tracheostomy tube and a feeding tube

  The purpose of these facilities is to wean patients off of their tracheostomies, if possible, and to transition them on to either rehabilitation or to a long term care facility

  There is a shortage of this level of care in Northern California

  Neurosurgery Clinic

  Traumatic Brain Injury Clinic

  Concussion Clinic

  Neurotrauma Outreach Program (NTOP)

  TBI Support Group

  Immediate Hospital DC Follow-up

  Every Tuesday Morning

  Appointment Scheduling ◦  eReferral ◦  Direct Phone Line (415) 206-4420

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  Mission ◦  To provide transdisciplinary care for the patient with traumatic

brain injury enhancing overall recovery, facilitating reintegration into the community, promoting emotional well-being, and providing supportive educational information.

  Trans-Disciplinary Team

  First Thursday of Every Month

  Appointment Scheduling ◦  eReferral

  Mission ◦  To provide multidisciplinary and supportive care for

the patient with mild traumatic brain injury thru post-concussive assessment and symptom targeted patient education

  Multi-disciplinary

  Third Thursday of Every Month

  Appointment Scheduling ◦  eReferral

  Emphasis upon assertive tracking, outreach, and engagement into services

  Clinical case management to address all basic needs (medical, legal, financial, housing, services etc.)

  Coordination of care across medical, psychiatric, psychosocial, rehabilitation and social services

  Evidence-based psychotherapy to target psychiatric distress, increase interpersonal safety and help clients cope with the cognitive and behavioral changes associated with TBI.

  Currently employees ◦  Neuropsychologist ◦  Two full time licensed Social Workers

  Statistics ◦  NTOP provides services to 200 TBI patients annually

with approximately 100 of those patients receiving more in-depth outreach services

  Mission: ◦  To provide emotional support and education to TBI

patients and their families who are living with a traumatic brain injury.

  What does the TBI Support Group Provide ◦  Traumatic Brain Injury Education ◦  Peer Support and Mentoring ◦  Community resource referrals ◦  Invited speakers from numerous specialties

(Neurology, Nutrition, Sleep, Rehabilitation, ect).

  Post-concussive Symptoms

  Need for Neuropsychology Testing

  Psychosocial Issues

  Reintegration in the Community

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  More than 75% of all Mild TBI patients report 1or more Symptoms

  Signs and Symptoms ◦  Physical

◦  Cognitive

◦  Emotional

◦  Sleep

  Patient Education ◦  Pt’s who receive education around the s/s of concussion

and the trajectory of recovery experience fewer symptoms overall   Folders

Leaders in Traumatic Brain Injury care

  ICP Monitoring in patients with GCS <8

  Seizure Prophylaxis

  VTE Prophylaxis

  IDT Review

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TBI Program - NSU StatsMay 2010 - December 2010

(509 Total Patient Encounters)

Random Sample of TBI Chart Audits

TBI Program2010 Performance Improvement

Intracranial Pressure (ICP) Monitoring

Quality Indicator: Intracranial Pressure (ICP) Monitoring

Random sample of patients who have sustained a moderate to severe head injury and have a GCS < 8

The following patients are excluded: death/comfort care, improving GCS / exam, coagulopathy, otherclinical indications

TBI Program2010 Performance Improvement

Seizure Prophylaxis

Quality Indicator: Seizure Prophylaxis (7 days of anti-seizure medication)

Random sample of patients with TBI and abnormal CT scan

The following patients are excluded: isolated subarachnoid hemorrhage, clinical contraindication

TBI Program2010 Performance Improvement

DVT Prophylaxis

Quality Indicator: DVT Prophylaxis

Random sample of patients with TBI

The following patients were excluded: ambulatory, coagulopathic, other clinical contraindications

TBI Program2010 Performance Improvement

Interdisciplinary Team ( IDT) Rounds

Quality Indicator: Interdisciplinary Team (IDT) Rounds

Random sample of admitted TBI patients who have sustained a mild, moderate, or severe head injury

The following patients are excluded: hospital length of stay (LOS) < 7 days

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www.brainandspinalinjury.org Questions?