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Cerebral protection in a patient with an isolated closed head injury (Main…
Cerebral protection in a patient with an isolated closed head injury
Brain injury has 2 forms:
Primary injury
Injury at time of insult
Severity determined by degree of neuronal damage
Major determinant of outcome, difficult to modify
Secondary injury
Reduction in cerebral substrate utilization
Propagates or initiates processes which may fatally damage already susceptible neurones
Main objectives:
Defend cerebral perfusion pressure (CPP) - CPP = MAP - (greater of) ICP or CVP
Optimise MAP (avoid hypotension)
Minimise ICP
Optimise venous drainage
Position head up 30-45 degrees
Avoid neck ties, collar, neck rotation
PEEP < 10cm H20
Chemical
low normal C02 (35cm H20)
Normal 02, normal pH
Avoid cerebral vasoconstriction or vasodialtion
May require intubation and intubation to control this
Munroe-Kellie doctrine
Surgical measures
ICP drains
Decompessive craniotomy
Evacuate haematoma / space occupying lesion
Medical measures:
MAP maintenance through inotropes/vasopressor and fluid resus
Mannitol or hypertonic saline to draw water into vascular space
Aim CPP > 60mmHg
Autoregulation may be lost globally or locally, proportional to MAP
Optimise CMR02
Optimise 02 delivery
Determined by CBF
Cardiac output - optimise MAP and HR
Blood 02 concentration (1.39 x Hb x %Sats + dissolved 02 (ensure adequate Hb and Sats)
Decrease cerebral metabolic rate
Proportional to temp - consider mild hypothermia (controversial)
Medical measures: thiopentone (reduce burst suppression), Paralysis (prevent coughing, straining, shivering), minimise pain / stress
Avoid factors exacerbating secondary injury
Hyper / hypoglycaemia (aim BSL 4-10)
Hyperthermia (avoid even if not actively cooling)
Seizures (seizure prophylaxis for first 7 days)