Management of the Decompensating Traumatic Brain Injury Patient. Objectives. Medical Emergency Response Team MERT 12/1/15
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1 Management of the Decompensating Traumatic Brain Injury Patient Yesenia Renteria, RN, MSN San Francisco General Hospital Medical Emergency Response Team Objectives! What is the goal of the Medical Emergency Response Team! Overview of the types of traumatic brain injuries! Factors that exacerbate traumatic brain injuries! Identify the acute decompensating traumatic brain injury patient! Interventions prior and during the MERT activation! Key points to transferring to a higher level of care! Case studies! WHO is MERT! WHAT is MERT Medical Emergency Response Team MERT! WHERE is MERT! WHY is there a MERT! WHEN is there a MERT 1
2 Increase Mortality Associated with 6.8 fold increase in mortality (95%, CI )! Bradycardia <30 beats/minute! Systolic Blood Pressure <90mm/hg! Oxygen Saturation <90 percent! Respiratory Rate <6 breaths/miniute! A Decrease in Glasgow Coma Scale by 2 points! Onset of Coma Buist M, Bernard S, Nguyen TV, et al. Association between clinically abnormal observations and subsequent in hospital mortality: a prospective study. Resuscitation 2004; MERT Activation Goals! Communication! Effective and timely interventions! Avoid delays in ICU transfers 2
3 Injuries to the Brain! Focal Lesions! Contusion! Lacerations! Hemorrhage! Epidural hematoma! Subdural hematoma! Subarachnoid hemorrhage! Intracerebral hematoma Stages of Brain Damage after Trauma! PRIMARY- occur at moment of injury! Surface contusions and lacerations! Diffuse axonal injury! Intracranial hemorrhage 3
4 Stages of Brain Damage after Trauma! Secondary- initiated at moment of injury! Ischemia! Electrolyte imbalances! Neuronal injury cascade! Edema (elevated intracranial pressure)! Delayed hematoma formation GOALS OF TREATMENT Treat Primary Injury Prevent Secondary Injury Factors which exacerbate secondary brain injury! Hypoxia PaO 2 <60mmHg! Hypo/hypercapnea! Hypotension systolic pressure < 90mmHg! Fever! Seizures! Hypo/hyperglycemia! Hyponatermia! Intracranial hypertension ICP >20 (CPP) 4
5 Complications! Herniation! Cerebral salt wasting! Seizures Signs & Symptoms of Increased ICP! Altered LOC! Headache! Nausea & vomiting! Seizures! Restlessness/agitation! Pupillary changes! Motor dysfunction! Changes in vital signs! Cranial nerve palsies! Papilledema 5
6 Cerebral Salt Wasting! CSW is characterized by hyponatremia and extracellular fluid depletion due to inappropriate sodium wasting in the urine! Sodium<135! Typical onset of hyponatremia is within the first 10 days following a neurosurgical procedure or event. Signs and Symptoms of Hyponatremia! Headache! AMS! Hypotension! Seizures! Irritability! Muscle spasms/cramps/weakness! Increased Hematocrit! Complication of TBI Seizures! Early vs Late = different implications Early: Within one week of head trauma Low likelihood of recurrence Late: More than one week of head trauma Represent epilepsy. 6
7 Seizure Prophylaxis! Phenytoin: does not cause significant sedation! Total phenytoin levels = Bound and unbound phenytoin drug level! Protein bound phenytoin can not cross the blood brain barrier! Only free unbound phenytoin is active! Phenytoin binds to albumin:! Approximately 90% of phenytoin binds in healthy adults! Therapeutic level:10-20 µg/ml! Corrected phenytoin level! Sheiner-Tozer method calculation: TBI Patient Assessment! Know your patient! Dx: type of brain injury! DAI vs. SDH! Date of injury/hospital day/post op day! Baseline neurological exam! Neurological exam with previous shift RN! Hospital course/complications! ICU/ED transfer vs. Floor transfer! History of TBI seizures! Hospital Day! Day 1 vs Day 20! On seizure prophylaxis? 7
8 Glasgow Coma Score (GCS) Motor Obeys 6 Localizes 5 Withdraws 4 Flexion 3 Extension 2 No response 1 Verbal Oriented 5 Confused 4 Inappropriate Words 3 Sounds 2 No sounds 1 Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1 Severe head injury = GCS 8 Opening one liner: Communication! Describe who the patient is.! Number of days in hospital.! Main clinical issue(s).! Highlighting changes in clinical status:! Vital signs! Physical exam findings (highlighting changes)! Relevant labs (highlighting changes)! Pertinent data: FS, Sedation, visitors! Concerns Communication 8
9 Interventions! Positioning! Supplement 02! IV access! Blood pressure! POC: Finger stick! Labs: CBC, Chem10, Osmolarity, Coags, ABG! Prepare for Urgent Head CT! HOB up 30! Head midline! Avoid hip flexion Postition! Reverse Trendelenburg for uncleared spine CT Scan Transport! Always be prepared.! Time is brain cells 9
10 Transfer to Intensive Care Unit! Communication! MERT team! Primary team! Charge Nurses! Pharmacy! Supportive staff! Equipment: ABC s! ABC s! Medications! Fluids CASE STUDY Case study #1! 18 y.o male, S/P fall 30 feet from balcony,! GCS in field 9 (E4, V1, M4) GCS 6 in ED (E1, V1 M4),! Bilateral pupils 6mm sluggish.! Positive brain stem reflex! CT scan showed:! Right frontal EDH! Right SDH! Right frontal contusion! Emergent OR! Right Craniotomy for evacuation of EPH and SDH 10
11 ! Post surgery:! GCS: 15! Bilat Pupils 3mm brisk Case study #1! POD 4! Transferred from ICU to the floor 11
12 Case study #1! GCS 14-15! Obeys commands! Oriented to person place time and situation! Opens eyes to speech! Bilateral pupils equal 3mm but fluctuating from brisk to sluggish Case Study #1! End of the shift 18:30! Obeys commands! Oriented to person place and situation but not time! Opens eyes to speech! Bilateral pupils equal 3mm but sluggish Glasgow Coma Score (GCS) Motor Obeys 6 Localizes 5 Withdraws 4 Flexion 3 Extension 2 No response 1 Verbal Oriented 5 Confused 4 Inappropriate Words 3 Sounds 2 No sounds 1 Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1 Severe head injury = GCS 8 12
13 ! What do you do? Case study #1! Communication! Effective and timely interventions! Avoid delays in ICU transfers 13
14 Case Study #2! 30 yo male found down 2/2 Ped vs. Auto! GCS in field 7 (E1 V1,M5). GCS in ED 10 (E4,V1,M5)! Pupils 3mm brisk bilateral! No movement to right side! CT scan showed:! SAH! Left SDH! Right internal carotid dissection! Right scapula bone fracture Case Study #2! Emergenct OR! Left SDH evacuation! Left decompressive craniectomy! Neuro exam post op and ICU! GCS 10 (E4, V1,M5)! Pupils 3mm brisk bilateral! Moving all extremities equally! Hospital day 5! Transferred to the floor 14
15 Case Study #2 Noon assessment! Patient is having a seizure! Communication Case Study #2! Effective and timely interventions! Avoid delays in ICU transfers! Patient Safety! Activate the MERT! Anticipate interventions! Medications! IV access! Labs! Fluids Case Study #2! Prepare for emergent CT or ICU transfer 15
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3. Overview: The next 8 pages contain the concussion management algorithms guiding garrison medical care at the time of injury to 7 days.
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