Transcript NEUROTRAUMA - Kenyatta National Hospital

DR. P.K WANYOIKE
CONSULTANT NEUROSURGEON
1ST TRAUMA SYMPOSIUM
KENYATTA NATIONAL HOSPITAL
19-04 2013
ACUTE NEUROTRAUMA
 ACUTE TRAUMATIC BRAIN INJURY
 ACUTE SPINAL CORD INURY
NEUROTRAUMA(stadards for surveilance of
neurotrauma, who, cdc 1995)
 TRAUMATIC BRAIN INJURY-Defined as
injury to the head {blunt or penetrating
trauma by either accelerating or
decelerating forces } and with either
 1)observed or self reported loss of
consciousness.
 2)Neurologic or psychological changes, skull
fracture or intracranial lesions
 3)Death as a result of trauma in patient with
head injury
PENETRATING
MISSILE TBI
EXCLUDES
 Lacerations, avulsions or contusions of the face, ear,
eyes, scalp without the criteria above
 Fractures of facial bones
 Birth trauma
 Inflammatory, Infections metabolic, or
encephalopathies not related to brain trauma
 Cerebral anoxia and brain infarction not trauma
related
 Brain tumors
SPINAL TRAUMA
 Acute traumatic lesion of neural elements in the spinal
canal(spinal cord or cauda equina) resulting in
temporary or permanent sensory deficit, motor deficit,
or autonomic dysfunction. It maybe complete or
incomplete.
 EXCLUDES SPINE FRACTURES WITHOUT
NEUROLOGICAL DEFICIT
COMPLETE TRANSECTION
 DECOMPRESSION
 STABILIZATION
 NEUROLOGY
 UNCHANGED
 EARLY REHAB.
 BURST COMPRESSION
 CAUDA EQUINA
 MOTOR GRADE 2
 LORDOSIS MAITAINED
 FULL POWER REGAINED
 SPHICTERS REGAINED
 GOOD PRE-HOSP. CARE
 FROM DJIBOUTI TO NRB
 AND BACK
HAPPY PATIENT AND DOCTOR
INTRODUCTION
 TRAUMATIC BRAIN INJURY (TBI) IS A MAJOR
CAUSE OF DISABILITY, DEATH AND ECONOMIC
COST TO OUR SOCIETY.
 NEUROLOGICAL DAMAGE EVOLVES OVER
ENSUING HOURS AND DAYS DUE TO SECONDARY
AND DELAYED INSULTS
KNH 2012 STATISTICS
 ACUTE TRAUMA----5358
 HEAD INJURIES------1513(28%)
 SPINE-------------------150
 PERCENTAGE NEUROTRAUMA---31%
ENTRY POINT
WELL EQUIPED EMMERGNCY
ROOM
KNH ACUTE ROOM
MORTALITY
 USE OF EVIDENCE BASED PROTOCALS HAS
REDUCED MORTALITY FROM 50% TO 35% TO 25%
OVER THE LAST 30 YEARS (j. of neurotrauma 2007)
 AUDIT OF ICU ADMISSIONS BETWEEN JAN AND
MARCH 2013 AT KNH SHOWED A MORTALITY
RATE OF 30% TO 40%
 AUDIT OF 105 CASES BETWEEN JUNE AND DEC
2012-SHOWED A MORTALITY OF 19%.
FIVE MOST POWERFUL
PREDICTORS OF OUTCOME IN
SEVERE TBI PTS.
 HYPOTENSION(SBP LESS THAN 90mHg)
 AGE
 ADMISSION GCS
 INTRCRANIAL DIAGNOSIS
 PUPILLRY STATUS
HYPOTENSION AND OXYGENATION
 AVOID SBP <90mmHg(
 Avoid hypoxia(PaO2 <60mmHg or O2
saturation<90%)
 Median hypoxemia of 11.5 to 20mins-a powerful
predictor of mortality(p=0.024)
 Chestnut rm,Marshall lf.,Klauber mr,et.al the role of secondary brain
injury in determining outcome from severe head injury.j trauma
1993:34:216-222
AGE
 AGE IS AN IDEPEDENT PREDICTOR OF
MORTALITY AND EARLY OUTCOME
 ADULTS > 75YRS. HAVE HIGHEST MORTALITY
FOLLOWED BY INFANTS 0-4YRS. AND
ADOLESCENTS 15-19 YRS.
GCS
 MOTOR-1unresponsive,2 extends, 3abnormal flexure,
4 withdraws, 5 localises, 6 spontaneous
 VERBAL-1 no response, 2 incomprehensible,3
inapropriate, 4confused, 5 oriented
 EYE OPENING-1 none, 2to pain, 3command, 4
spontaneous
GLASGOW OUTCOME SCORE
 1 DEATH
 2PERSISTENT VEGETATIVE STATE
 3SEVERE DISABILITY
 4 MODERATE
 5 MILD DISABILITY
 APPLIES TO PATIENTS WITH BRAIN DAMAGE
ALOWING OBJECTIVE ASSESMENT OF THEIR
RECOVRY,REHABILITATION AND RETURN TO
WORK
PREDICTIVE INDICATORS
 GCS < 7
 CT SCAN – LARGE CLOT AND MASSIVE
BIHEMISPHERIC CLOT
 AGE – OLD AGE
 PUPILLARY LIGHT REFLEX –DILATED PUPIL
 DOLLS EYE SIGHN- ABSENT
 CALORIC TEST- EYES DO NOT DEVIATE
 MOTOR RESPONSE – DECEREBRATION
 POSTTRAUMATIC AMNESIA > 2 WEEKS
MANAGEMENT FACTORS
INFLUENCING OUTCOME IN
SEVERE TBI PTS.
 Blood pressure and oxygenation
 Hyper-Osmolar therapy
 Prophylactic hypothermia
 Infection prophylaxis
 DVT prophylaxis
 ICP monitoring
 Cerebral perfusion
 Anesthesia, analgesics and sedatives
 Nutrition
 AEDs (anti-seizure prophylaxis)
 Hyperventilation
Hyperosmlar therapy
 Mannitol 0.25mg to 1g/kg body weight.
 Single loading dose or as a prolonged therapy for
raised icp
 Lower bp and cpp
 Hypertonic saline-lowers icp while maintaining
hemodynamics( esp. important In pediatrics)
 Spcial precaution of central myelinosi in pts. With
hyponatremia
Hypothermia
 Evidence from 6 RCTs have not shown any statiscally
sinificant reduction in mortality but there was
favourable neulological outcomes.
 Alderson p.et. Altherapeutic hypothermia for head
injury.cochrane database syst. Rev. 2004:4:CDOO1048.
Infection prophylaxis
 Periprocedural antibiotics for intubation to reduce
incidence of pneumonia RECOMEDED
 Routine Ventricular catheter antibiotic prophylaxis is
not recomeded
 ventyriculostomies and icp monitors should be placed
under sterile conditions
 prolonged antibiotics use in intubated tbi pts leads to
ressistance.
DVT PROPHYLAXIS
 Graduated compression stockings or intermittent
pneumatic compressiuon (IPC)stockings
 Low molecular weight heparin or low dose unfractionated
heparin(risk of expansion of intracranial hemorrhage)
 No medication of choice or optimal dosing according to
current evidence
 Nurmohammed mt. et, al.low molecular weihgt heparin
andcompression stockingsin the prevention of dvt in
neurosurgery. Thromb hemostat1996:75:233-238
ICP MONITORING
 Should be done in all salvageable patients with severe
traumatic brain injury(GCS of 3-8 after resuscitation)
and an abnormal ct scan.
 IN patients with a TBI and normal ct scan, ICP
monitoring is indicated if two of the following are
noted.age >40yrs.unilateral or bilateral motor
posturing or SBP<90mmHg.
 Cremor o et al. effect of intracranial pressure
monitoring and targeted intensive care on functional
outcome after severe head injury.crit. Care
med2005:33:2207-2213
ICP MONITORING TECHNOLOGY
 VENTRICULAR CATHETER CONNECTED TO AN
EXTERNAL STRAIN GAUGE-the most accurate, low cost
and reliable method of monitoring icp.and can be recalibrated in situ
 PARENCHYMAL ICP MONITORS CANNOT BE RECALIBRATED
 Treatment initiated with ICP THRESHOLD ABOVE 20 mm
Hg
 Need for treatment based on a combination of icp values,
clinical and brain CT scan findings
 Saul TG, Ducker TB. Effects of intracranial of intracranial pressure
monitoring and aggressive treatment on mortality in severe head
injury. J neurosurg1982 56: 498-503
Cerebral perfusion
 Aggressive attempts to maintain CPP above 70 mmHg
with fluids and pressors should be avoided because of
the risk of adult respiratory distress syndrome – ARDS
 CPP< 50 mmHg should be voided as its associated
with poor outcome due to low cerebral perfusion and
hence cerebral hypoxia.
 RANGE 50-70 mmHg
 Bouma CJ et al blood pressure and intracranial pressure-volume
dynamics in severe head injury:relationship with cerebral blood
flow.j neurosurg 1992 77: 15-19
BRAIN OXYGEN THRESHOLD
 JUGULAR VENOUS OXYGEN SATs 50- 55
ASSOCIATED WITH POOR OUTCOME (SjO2<5055).
Anesthetics, analgesics and
sedatives
 High dose barbiturates administration is
recommended to control ICP refractory to maximum
standard medical and surgical treatment.
 Propofol is recommended for control of ICP but High
doses can produce significant morbidity
 Cruz j adverse effects of pentobarbital on cerebral venous oxygenation of
comatose patients with acute traumatic brain swelling. relationship to
outcome.j neurosurg1996:85 758 761.
NUTRITION
 AIM IS TO ACHIEVE FULL CAROLIC
REPLACEMENT BY 7DAYS.
 START FEEDING NO LATER THAN 72 HOURS
AFTER INJURY
 EITHER GASTRIC, JEJUNAL OR PARENTERAL
 DATA SHOW THAT STARVED TBI PATIENTS LOSE
SUFFICIENT NITROGEN TO LOSE WEIGHT BY 15%
PER WEEK
 HUCKLEBREBERY ET AL .NUTRITIONAL SUPPORT AND THE
SURGICAL PATIENT.AM J HEALTH SYST PHARM 2004:61:671-4
ANTI EPILEPTIC DRUGS
 INDICATED IN ACUTE TBI WITH EARLY ONSET
SEIZUERS
 CANNOT PREVENT LATE ONSET SEIZURES HENCE
NO ROLE FOR PROPHYLAXIS
 PROPHYLAXIS IN COMATOSE AND INTUBATED
PATIENTS
USE OF STEROIDS
 CONTRAINDICATED IN ACUTE TBI
 CURRENT EVIDENCE SHOW AN 18% RISK OF
DEATH IN PATIENTS ADMINISTERD STEROIDS TO
THOSE NOT ON STEROIDS
 Alderson et al.Corticosteroids for acute traumatic brain injury. The
database for of systemic reviews 2005, issue 1
BEST OUTCOME
 EFFICIENT PRE-HOSPITAL CARE
 GOOD HOSPITAL CARE
 ACUTE RESUSCITATION
 HEMODYNAMIC NORMALIZATION
 EARLY BRAIN CT SCAN
 SURGICAL AND /OR MEDICAL INTERVENTION
 ADEQUATE CRITICAL CARE
 REHABILITATION
GOOD DEDICATED THEATER
AMERICAN STATISTICS(cdc)
 1.4 million americans sustain TBI annually
 50,000 people die
 475,000 children and adolescents 0-14 years
 80000-90,000 long term disability
 Males twice as likely to sustain tbi than females
 Falls, mvas,trauma, assault( mvas , assault,falls,
trauma--knh)
AVOID THIS
LOOKS LIKE BRAIN
DON’T TOUCH
WHAT IS THE KENYAN SITUATION
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SYMPOSIUM
KNH NEUROSURGERY