dr. p.k wanyoike consultant neurosurgeon 1 st trauma symposium kenyatta national hospital 19-04 2013
TRANSCRIPT
DR. P.K WANYOIKECONSULTANT NEUROSURGEON
1ST TRAUMA SYMPOSIUMKENYATTA NATIONAL HOSPITAL
19-04 2013
ACUTE NEUROTRAUMAACUTE 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
EXCLUDESLacerations, avulsions or contusions of the
face, ear, eyes, scalp without the criteria above
Fractures of facial bonesBirth trauma Inflammatory, Infections metabolic, or
encephalopathies not related to brain traumaCerebral anoxia and brain infarction not
trauma relatedBrain tumors
SPINAL TRAUMAAcute 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
DECOMPRESSIONSTABILIZATIONNEUROLOGY UNCHANGEDEARLY REHAB.
BURST COMPRESSION CAUDA EQUINAMOTOR GRADE 2
LORDOSIS MAITAINEDFULL POWER REGAINEDSPHICTERS REGAINEDGOOD PRE-HOSP. CAREFROM DJIBOUTI TO NRBAND BACK
HAPPY PATIENT AND DOCTOR
INTRODUCTIONTRAUMATIC 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 STATISTICSACUTE TRAUMA----5358HEAD INJURIES------1513(28%)SPINE-------------------150PERCENTAGE NEUROTRAUMA---31%
ENTRY POINT
WELL EQUIPED EMMERGNCY ROOM
KNH ACUTE ROOM
MORTALITYUSE 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)AGEADMISSION GCSINTRCRANIAL DIAGNOSISPUPILLRY STATUS
HYPOTENSION AND OXYGENATIONAVOID 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
AGEAGE IS AN IDEPEDENT PREDICTOR OF
MORTALITY AND EARLY OUTCOME
ADULTS > 75YRS. HAVE HIGHEST MORTALITY FOLLOWED BY INFANTS 0-4YRS. AND ADOLESCENTS 15-19 YRS.
GCSMOTOR-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 SCORE1 DEATH2PERSISTENT VEGETATIVE STATE3SEVERE DISABILITY4 MODERATE5 MILD DISABILITYAPPLIES TO PATIENTS WITH BRAIN
DAMAGE ALOWING OBJECTIVE ASSESMENT OF THEIR RECOVRY,REHABILITATION AND RETURN TO WORK
PREDICTIVE INDICATORSGCS < 7CT SCAN – LARGE CLOT AND MASSIVE
BIHEMISPHERIC CLOTAGE – OLD AGEPUPILLARY LIGHT REFLEX –DILATED PUPILDOLLS EYE SIGHN- ABSENTCALORIC TEST- EYES DO NOT DEVIATEMOTOR RESPONSE – DECEREBRATIONPOSTTRAUMATIC AMNESIA > 2 WEEKS
MANAGEMENT FACTORS INFLUENCING OUTCOME IN SEVERE TBI PTS.Blood pressure and oxygenationHyper-Osmolar therapyProphylactic hypothermiaInfection prophylaxisDVT prophylaxisICP monitoringCerebral perfusionAnesthesia, analgesics and sedativesNutritionAEDs (anti-seizure prophylaxis)HyperventilationSteroids
Hyperosmlar therapyMannitol 0.25mg to 1g/kg body weight.Single loading dose or as a prolonged
therapy for raised icpLower bp and cppHypertonic 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 prophylaxisPeriprocedural antibiotics for intubation to
reduce incidence of pneumonia RECOMEDED Routine Ventricular catheter antibiotic
prophylaxis is not recomededventyriculostomies and icp monitors should
be placed under sterile conditionsprolonged antibiotics use in intubated tbi pts
leads to ressistance.
DVT PROPHYLAXISGraduated 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 MONITORINGShould 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 TECHNOLOGYVENTRICULAR CATHETER CONNECTED TO AN
EXTERNAL STRAIN GAUGE-the most accurate, low cost and reliable method of monitoring icp.and can be re-calibrated in situ
PARENCHYMAL ICP MONITORS CANNOT BE RE-CALIBRATED
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 perfusionAggressive 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 mmHgBouma 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 THRESHOLDJUGULAR VENOUS OXYGEN SATs 50- 55
ASSOCIATED WITH POOR OUTCOME (SjO2<50-55).
Anesthetics, analgesics and sedativesHigh 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.
NUTRITIONAIM IS TO ACHIEVE FULL CAROLIC
REPLACEMENT BY 7DAYS. START FEEDING NO LATER THAN 72 HOURS
AFTER INJURYEITHER GASTRIC, JEJUNAL OR PARENTERALDATA 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 DRUGSINDICATED IN ACUTE TBI WITH EARLY
ONSET SEIZUERSCANNOT PREVENT LATE ONSET SEIZURES
HENCE NO ROLE FOR PROPHYLAXISPROPHYLAXIS IN COMATOSE AND
INTUBATED PATIENTS
USE OF STEROIDSCONTRAINDICATED 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 OUTCOMEEFFICIENT PRE-HOSPITAL CAREGOOD HOSPITAL CAREACUTE RESUSCITATIONHEMODYNAMIC NORMALIZATIONEARLY BRAIN CT SCANSURGICAL AND /OR MEDICAL
INTERVENTIONADEQUATE CRITICAL CAREREHABILITATION
GOOD DEDICATED THEATER
AMERICAN STATISTICS(cdc)1.4 million americans sustain TBI annually50,000 people die475,000 children and adolescents 0-14 years80000-90,000 long term disabilityMales twice as likely to sustain tbi than
femalesFalls, mvas,trauma, assault( mvas ,
assault,falls, trauma--knh)
AVOID THIS
LOOKS LIKE BRAIN
DON’T TOUCH
WHAT IS THE KENYAN SITUATIONFOOD FOR NEXT SYMPOSIUM
KNH NEUROSURGERY