? "a blow to head or a penetrating head injury
that disrupts the function of brain"
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? One lakh lives are lost every year due to TBI in
India
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? Nearly 95% trauma victims do not receiveoptimal care during `Golden Hour' period
? Among them 30% of lives could be saved if
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quality care were available to them sooner
Global data on TBI
? 50 million injured every year
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? Estimated deaths ? 1.2 million? Global mortality: 97/1,000,000
? 70 % fatalities (8,500,000) under 45 years of age
? WHO Research Predicts by 2020:
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? 80 % increase in developing countries? 147 % increase in road traffic accidents (RTA)
deaths in India/Rajasthan
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Indian data on TBI? 60% of all TBI caused by RTA
? Fatality rate: 70 per 10,000 vehicles
? 25X higher than in developed countries
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? One person dies in India every 6 - 10 mins; willbe every 3 mins by 2020
? "vulnerable road users":
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- Pedestrians (25 %),- Motorcyclists (17 %),
- Four-wheel vehicle operators (15%),
- Pedal cyclists (10 %).
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? By 2050, India will have the greatest number
of automobiles on the planet, overtaking the
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United States.? A study conducted by CRRI-
? Increase traffic congestion in Delhi might
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actually have resulted in fewer accidents overlast year.
Pathophysiology of Traumatic Brain Injury
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TBI10 Injury to brain
ICP
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Inlammation/edema/excitotoxicity
ICP CPP
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Secondary injuries to brainSecondary insults contributing to
hypoxic/ ischemic brain damage
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Systemic
intracranial
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HypoxemiaHematoma
Hypotension
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Raised ICP
Anemia
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SeizuresHypo/hyper carbia
Infection
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Pyrexia
Vasospasm
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HyponatremiaHypo/hyper glycemia
Importance of perioperative period
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? Most of the poor outcomes after severe head injuryare related to presence of pre-hospital secondary
insults
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? Perioperative period provides an opportunity to
continue and refine ongoing resuscitation and to
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correct pre-existing secondary insults? Perioperative period may be a window to initiate
interventions, that may improve the outcome of TBI
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Does the "Golden Hour" After Injury
Really Matter?
Golden hour
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? A traditional dogma- trauma patients should
reach the hospital and to be treated with in one
hour of injury
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? First described by R Adams Cowley in 1975
? Several studies have suggested a decrease in
mortality when trauma patients reach definitive
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care during the Golden Hour, but recent researchdemonstrates no link between time and survival.
? Although prehospital time should be minimized, the
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use of lights and sirens and air transport entail costsand risks that must be weighed against possible
benefit for each patient.
? Also, for really seriously injured patients, arrival at
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the right place (a Level I trauma center) is probably
much more important than the out-of-hospital time.
- Newgard CD et al. Ann Emerg Med 2015 Jan 14.
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Goals of perioperative management ofTBI
? The key elements of TBI management-
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?Early resuscitation?Hemodynamic optimization
?Emergent surgical evacuation of mass lesion
?Control of ICP
?Support of CPP
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?Optimization of physiological milieuPrehospital Management
? Emergency therapy should begin at the site of
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accident and in the ambulance
? EMS providers- should be trained to follow an
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established algorithm for assessment andtreatment of TBI
? The first priority is initiation of basic
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resuscitation protocol, prioritizing the ABCs? Severely head injured patient to be directly
taken to level I trauma centre- BTF
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Emergency Department Management? The initial assessment and stabilization-
achieved as soon as the pt arrives in the ED
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? Evaluation of ABCs
?Rapid assessment of neurological status,
pupillary response
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?Associated extra cranial injuries
?Evaluation of anemia/ coagulopathy/ glycemia
?Adequate vascular access
? Non contrast CT scan is radiological procedure
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of choice
Airway management
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? Airway management in TBI is complicated-? urgency of situation
?Uncertainty of cervical spine status
?Uncertainty of airway
?Full stomach
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?Intracranial hypertension?Uncertain volume status
Technique - Best Practices
? Choice of technique depends upon-
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?Urgency /Individual expertise/ Availableresources
? Generally incorporates RSI with cricoid pressure
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and MILS
? Newer airway devises, particularly
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videolaryngoscopes, may be useful in difficultairway scenarios
? Nasal intubation- avoided in patients with base of
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skull fracture, severe facial fractures or bleeding
diathesis.
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? Appropriate pharmacological selection isimportant
? Sodium thiopental, etomidate and propofol
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decrease cerebral metabolic rate for oxygen
(CMRO2) and attenuate increases in ICP with
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intubation? Propofol & Thiopental may cause CVS depression
leading to hypotension
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? Etomidate- hemodynamic stability during
induction? Adrenal insufficiency
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? The choice of muscle relaxant for RSI issuccinylcholine or rocuronium
? Succinylcholine may contribute to increased ICP
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the clinical significance?
Anesthetic Management
? The major goals of anesthetic management of
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TBI are-
?To facilitate early decompression
?Provide adequate analgesia and amnesia
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?Treat intracranial hypertension and maintainadequate cerebral perfusion
?Provide optimal surgical conditions
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?Avoid secondary insultsAnesthetic technique
? IV or volatile anaesthetic agents?
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? There is little evidence to support the use ofone over the other
? All volatile agents reduce CMRO2, produce
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cerebral vasodilatation- resulting in increased
CBF and ICP.
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? However, at concentrations up to 1 MAC theseeffects are minimal
? Sevoflurane appears to have the best profile.
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? N2O is best avoided? I.V. agents reduce CMRO2, CBF, and ICP.
? Neuromuscular drugs are recommended to
prevent coughing or straining
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Ventilation
? Ventilation should be adjusted to ensure adequate
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oxygenation (PaO2 > 60 mmHg) and normocarbia(PaCO2 35-45 mmHg).
? Monitoring arterial PaCO2 is recommended
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? Hypercarbia (PaCO2 > 45 mmHg) to be avoided? Hyperventilation should be used judiciously for
short-term control of ICP
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? Excessive and prolonged hyperventilation maycause cerebral vasoconstriction leading to
ischemia
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Monitoring? Multimodal monitoring
? American Society of Anesthesiology (ASA)
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monitors? Arterial catheterization is recommended for
continuous BP monitoring, ABG and glucose
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monitoring in patients who require surgical
intervention
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? ICP monitoring is recommended in allsalvageable patients with a severe TBI (GCS <
9) and an abnormal CT scan
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? Jugular venous oximetry is often useful for
assessment of adequacy of global cerebral
oxygenation
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? Brain tissue oxygen monitors have the
advantage of identifying focal areas of
ischemia which may not be picked up by
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jugular venous oximetry.? Near Infrared Spectroscopy (NIRS) offers the
capacity to conveniently and non-invasively
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monitor cerebral oxygen in the intensive careunit.
? Transcranial Doppler (TCD) ultrasonography
is a non-invasive, nonradioactive, bedside
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monitor, which can provide usefulinstantaneous cerebrovascular information
including changes in cerebral blood flow
velocity, cerebral vasospasm and
autoregulation
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Intravenous Fluids, Blood Pressure
Management and Vasopressor Use
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? BP management, including choice of fluids andvasopressors, is of paramount importance
? BTF guidelines for the management of TBI recommend
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avoiding hypotension (SBP < 90 mmHg) and
maintaining CPP between 50 and 70mmHg.
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? Perioperative hypotension should be treated promptly? Hypertonic saline may be beneficial resuscitation fluid
for TBI patients
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? Current evidence does not support preference of onevasopressor over the other to support cerebral perfusion
and the choice may have to be individualized to patient
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characteristics
Coagulopathy
? Coagulation disorders may be present in
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approximately one-third TBI patients and is
associated with an increased mortality and
poor outcome
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? Brain injury leads to the release of tissue factor.? Patients with GCS 8, associated cerebral
edema, SAH and midline shift are likely to
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have coagulopathyHyperosmolar therapy
? Mannitol is commonly used for hyperosmolar
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therapy
? The recommended dose of mannitol is 0.25-1
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g/kg body weight? In patients with severe TBI and elevated ICP
refractory to mannitol treatment, 7.5%
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hypertonic saline administered as second tiertherapy
Glycemic Control
? Hyperglycemia after TBI is associated with
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increased morbidity and mortality
? Hyperglycemia can cause secondary brain
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injury? Hypoglycemeia is equally deleterious to brain
? Given the current evidence for glucose control
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for TBI in perioperative period, a targetglucose range of 80-180 mg/dl is reasonable
Therapeutic Hypothermia and Steroids
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? Hypothermia reduces cerebral metabolism duringstress, reduces excitatory neurotransmitters
release, attenuates BBB permeability
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? Yet, clinical evidence in terms of mortality andfunctional outcomes is still inconclusive.
? Accordingly, the BTF/AANS guidelines task
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force has issued a Level III recommendation for
optional and cautious use of hypothermia for
adults with TBI
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