9/26/2013

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Initial Management of Brain & Spinal Cord Injury

STH Update Session, 2013

Dr Matt Wiles

Sheffield Teaching Hospitals NHS Foundation Trust

@STHJournalClub

http://sthjournalclub.wordpress.com/

Objectives

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Objectives

1. Traumatic Brain & Spinal Cord Injury

� Resuscitation

� BP targets

� Adjuvant therapy

2. Cerebrovascular Accidents

� Acute Intracerebral Haemorrhage

� Subarachnoid Haemorrhage

� Ischaemic stroke

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Epidemiology of TBI

• Incidence 400/100,000 per year

• Death 6-10/100,000 per year

• Leading cause of death 1-45 years

• 80% occur in males; 50% in children

• Significant financial cost

– By 2020, RTC will be the cause of 1/3 of the global health burden

Epidemiology

• Changing TBI population

.

Year n Median age

(years)

% aged > 50

years

Traumatic Coma Data Bank 1984-1987 746 25 15

UK Four Centre Study 1986-1988 988 29 27

EBIC Core Data Survey 1995 1005 38 33

Rotterdam Cohort Study 1999-2003 774 42 39

Austrian Severe TBI Study 1999-2004 492 48 (mean) 45

TARN Review 2003-2009 15173 39 (mean) Unknown

Italian TBI Study 2012 1366 45 44

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6863

54 56

39

1913

0

10

20

30

40

50

60

70

80

19-29 30-39 40-49 50-59 60-69 70-79 > 80

Series 1

Airway - Tracheal Intubation

• The stress response to laryngoscopy must be

attenuated – alfentanil 10-20 µg kg-1 is effective

• Ketamine is my first choice

• Propofol and thiopentone are alternatives

• Etomidate is contraindicated in head injury

• Most patients will require a RSI: suxamethonium and

rocuronium are both safe in brain injury

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Ketamine

Ketamine

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Ketamine

Ketamine

• Ketamine increases ICP/CBF in spontaneously

breathing volunteers (III)

• No effect on ICP with controlled ventilation

and sedation (III)

• Greater CPP maintained with ketamine and

lower vasopressor requirements (II)

• No effect on cerebral autoregulation (III)

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Breathing

• Hypoxia associated with worse outcome

• Marked hypo- and hypercapnia similarly bad

– Must calibrate PaCO2 with ETCO2

-2

-1

0

1

2

3

4

2 3 4 5 6 7

PaC

O2-E

TC

O2

Mean CO2 (PaCO2+ETCO2/2)

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Breathing

• Hypoxia associated with worse outcome

• Marked hypo- and hypercapnia simliarly bad

• What about PEEP?

CirculationChestnut et al. J Trauma 1993

• A single episode of hypotension doubles

mortality

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Circulation

• A single episode of hypotension doubles

mortality

• Head injury alone rarely causes hypotension

• Treatment of cardiovascular instability takes

precedence over direct head injury intervention

• No evidence for any one vasopressor

• Trials with permissive hypotension excluded

those with TBI

CirculationBerry et al. Injury 2011

� Retrospective analysis

� 15 733 patients with TBI following blunt trauma

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� Prospective work from TARN dataset

� 3444 patients with penetrating trauma

CirculationHassler et al. Resuscitation 2012

� Prospective work from TARN dataset

� 47 927 patients with blunt trauma

CirculationHassler et al. Resuscitation 2011

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Parameter BTF EBIC AAGBI

Respiratory AVOID

SpO2 <90%

PaO2 <8kPa

PaCO2 <3.3kPa

TARGET

SpO2 >95%

PaO2 >10kPa

PaCO2 4.0-4.5kPa

TARGET

PaO2 >13kPa

PaCO2 4.5-5.0kPa

Cardiovascular AVOID

SBP <90mmHg

TARGET

MAP >90mmHg

SBP >120mmHg

TARGET

MAP >80mmHg

Neurological ICP <20

CPP 50-70

(probably 60)

ICP <20-25

CPP 60-70

ICP <20-25

CPP 60-70

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Disability

• Short acting agents for sedation

• Atracurium

• How do I treat:

– Seizures?

• Incidence of 4-25% (in first week)

• Phenytoin effective as prophylaxis (RR 0.34)

• Effective dose 15-20 mg.kg-1

– Coning?

• Osmotherapy

• Hyperventilation - decrease PaCO2 to 4.0-4.5 kPa

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Osmotherapy

Osmotherapy

• Mannitol - no effect on mortality

• Both hypertonic saline (HTS) and mannitol

reduce ICP in the short term to similar degrees

• Both associated with morbidity if given in excess

• HTS may have a role in low-volume resuscitation

in trauma

– Highly irritant; best delivered centrally

– Potential for error is huge

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“The lack of improvement in head injured patients is

typified by the apparent overall lack of progress in head

injury care, which is suggested by the failure to identify

a single therapy to improve outcome despite over 250

randomised controlled trials.

However, several studies have shown that the

institution of packages of specialist neurosurgical or

neurocritical care is associated with improved

outcomes.”

Cerebrovascular AccidentsKisella et al. Neurology 2012

• Aging population, but a better treated one

• Shift in age incidence

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Intracerebral Haemorrhage

• Accounts for:

~10-15% of strokes in Western countries

~20-40% in African, Asian & Latin American populations

� The most lethal type of stroke

� No proven effective medical treatment

� Continued controversy over role of surgery

� STITCH-II now finished recruiting

� N=601

� Early (<12 h) surgery vs conservative

� No difference in GOSE

BP control following ICHOkumura et al. J Hypertension 2005

n = 1097

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BP control relates to outcome

Zhang et al. J Hypertension 2008

Ischaemic stroke

(n=2178)

ICH stroke

(n=1760)

BP normalisation after ICH (INTERACT)Anderson et al. Stroke 2009

• Intensive (SBP <140) vs. Standard (SBP < 180)

• Mean BP on arrival 180/100

• Reduction in haematoma size, but not outcome

Rapid BP lowering in ICH (INTERACT2)Anderson et al. NEJM 2013

• Intensive (SBP <140 in 1h) vs. Standard (SBP < 180)

• Mean BP on arrival 179/100

• No difference in death or disability

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Aim SBP 140-160 mmHg

Until ongoing clinical trials of BP intervention for ICH are completed,

physicians must manage BP on the basis of the present incomplete efficacy

evidence. Current suggested recommendations for target BP in various

situations are listed in Table 6 and may be considered (Class IIb; Level of

Evidence: C). (Unchanged from the previous guideline)

In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering

of systolic BP to 140 mmHg is probably safe (Class IIa; Level of Evidence: B).

(New recommendation)

Subarachnoid Haemorrhage

• 2-23/100 000 population

• Typical age of onset 50

• Mortality 44% UK (cf 32% USA)

• 8-20% persistent dependence

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Between the time of aSAH symptom onset and aneurysm obliteration, blood

pressure should be controlled with a titratable agent to balance the risk

of stroke, hypertension-related rebleeding, and maintenance of cerebral

perfusion pressure (Class I;Level of Evidence B). (New recommendation)

The magnitude of blood pressure control to reduce the risk of rebleeding has

not been established, but a decrease in systolic blood pressure to <160 mm Hg

is reasonable (Class IIa; Level of Evidence C). (New recommendation)

Aim SBP 140-160 mmHg

Triple HHH now out – euvolaemia

Consider TXA if delayed transfer (1g QDS)

Epidemiology of SCI

� Incidence 15-40 per million per annum

� cf TBI 4000 per million

� 70-80% occur in males

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Summary (TBI)

• Hypoxia & hypotension are bad for the brain

– Permissive hypotension has no place in TBI

– MAP > 80 mmHg

• Anything we can do to avoid these are good

(including ketamine, PEEP & calibration ETCO2)

• After any form of CVA aim for SBP 140-160mmHg

Airway & Cervical Spine

• Cervical spine 5% & Spinal cord 2.5%

• Triggers for intubation:

– Inability to maintain and protect own airway regardless of conscious level

– Inability to maintain adequate oxygenation with less invasive manoeuvres (PaO2 < 13kPa)

– Inability to maintain normocapnia (spontaneous PaCO2

<4.0 kPa or > 6.0kPa)

– GCS ≤8

– Patients undergoing transfer with:

• Deteriorating conscious level (≥2 points on motor scale)

• Significant facial injuries

• Seizures.

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Epidemiology of SCI

� Incidence by location

� Cervical 75%

� Thoracic 10%

� Lumbar 10%

� Incidence of fractures with SCI

� Cervical 40-50%

� Thoracic >95%

� Lumbar > 85%

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Cricoid Pressure

• Sellick (1961) n=26, in head down position

• Force of >44 N only effective in 50%

• BVM ventilation difficult in 50%

• Distorted view at laryngoscopy in 40%

• Only effective for 2-4 min (if at all!)

• No evidence that CP improves outcome

• BUT....

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Manual In-line Stabilisation

• Origin uncertain – ATLS guidance 1984

• Data from cadaveric studies, healthy

volunteers and case series (n=96)

• Direct laryngoscopy/intubation cause less

cervical movement than a jaw thrust

• Several studies suggest MILS has no effect on

cervical segment movement

Method Grade 1 Grade II Grade III

Optimal positioning 129 26 2

MILS 75 48 34

Neurological Deterioration after Surgery

• Due to prolonged deformation and/or hypotension

– Hyperflexion worse than hyperextension

• Both are unlikely during DL

• AFOI may not be safer

– Several claims in US Closed Claims Database

• 5% patients with SCI will deteriorate

– Early (24 h)

– Later (1-7 days)

– Late (weeks [post-traumatic ascending myelopathy])

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Steroids for Acute SCIBracken MB; Cochrane Database 2012

NASCIS II

• Design

– Multicentre, prospective, randomised, double-blind trial.

• Patients

– 487 patients with acute spinal cord injury (95% follow up)

• Exclusions

– Injuries below L1, children

• Randomisation

– Treatment 1: Methyprednisolone 30 mg/kg bolus, then 5.4 mg/kg/hr for 23 hours

– Treatment 2: Naloxone 5.4 mg/kg bolus, then 4.5 mg/kg/hr for 23 hours

– Treatment 3: Placebo

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NASCIS II

• Assessment

– Motor scale (0-5) in 14 muscle groups (total 70)

– Sensory (Pin prick & touch) in 29 dermatomes (total 58)

• (Author’s) Results

– Patients receiving steroids within 8 h had a statistically significant improvement of 5 points on the motor score at 6 months and 1 year (p=0.03)

• Safety

– Wound infection & PE doubled in steroid group (NS)

NASCIS II

• All +ve results are from post hoc analyses

• Time cut off (8 h) is arbitrary

• 78 discrete post hoc tests

• 60 t-tests for neurological outcomes

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Breathing

1. Fatigue of innervated muscles

2. Chest trauma

3. Ascension of the spinal lesion

4. Retained secretions

5. Abdominal distension splinting diaphragm

• Close observation

• Physiotherapy plus humidified oxygen

• Early tracheostomy

Circulation

1. Spinal shock

2. Co-existing (missed) traumatic injuries

• If lesion > T6, may need vasopressor support

• Caution with excessive fluids

• Target MAP > 80 mmHg

• ? Role of relative hypercarbia

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Clearing the Spine

Why bother?

• Avoidance of skin damage secondary to collars (6-67%)

– Ulceration

– Sepsis

• 30 degree head-up tilt to reduce pneumonia

• Exacerbation of raised ICP

• Increased demands on nursing care

• Exacerbation of agitation especially in TBI

Clearing the Spine

• 7 missed injuries of which 3 unstable

• Sensitivity/Specificity of CT >99.9% (cf NEXUS 99%)

• -ve LR < 0.001%

• 1 in every 4776 patients have missed injury

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(My) Rules for Clearing the Spine

• HRCT CT of C-spine (1-2 mm slices)

– C0 – T2 (but T4 better)

– Reported by consultant MSK/neuro radiologist

– Discussed with spinal/neurosurgical consultant

• [Consider AP/lateral C-spine radiographs]

• CT reconstructions of thoracolumbar spine

• AP/Lateral radiographs thoracolumbar views

NB. Semi-rigid collar (Aspen/Philadelphia) in interim.

Surgery

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Summary (SCI)

• Avoid hypotension & hypoxia

• Hypotension in SCI is bleeding until proved otherwise

– Trust no-one, believe nothing, give oxygen

• There is no place for steroid therapy

• Much of the best care is supportive & “SHO work”

– LMWH

– Stress ulcer prophylaxis

– Aperients

• Surgical timing is still uncertain