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Traumatic Brain Injury - Coggle Diagram
Traumatic Brain Injury
Classification
Mild = GCS>13
Moderate = 9-12
Severe = <8
Pathophysiology
Reduced cerebral oxygen
anaemia
Hypoxaemia
Hypotension
Increased ICP
Increased cerebral oxygen requriement
Seizures
Pyrexia
Cellular mechanisms
Excitoxicity
Inflammation
Hyperglycaemia
Free Radical Damage
Grading
Marshall for DAI
I = Nil visible = 10% mortaility
II =14%
Cisterns present
Midline shift <5mm
Small density lesions <25cc
III = 34%
Cisterns compressed/absent
IV = 56%
Midline shift
Investigations
ICP monitoring
CPP=MAP-ICP
Intraventricular catheter
Gold standard
Indications
Severe TBI / abnormal CT
Severe TBI + normal CT
Age>40
Motor posturing
SBP<90
Jugular bulb oxygen saturation
normal 50-75%
<50% necessitates intervention
Transcranial doppler
pulsatility index
EEG
Management
Neuroprotection
Normoxia pa02>10
Normocapnia paC02 4.5-5
Normotension MAP >80
Normoglycaemia 6-10
Normothermia
30 degrees head up
Aviod occlusion to venous drainage
Raised ICP
Sedation + NMBA reduce CMR02
Treat seizures
Keppra 1G
Phenytoin 18mg/kg
Osmotherapy
Hypertonic saline 1-2mls/kg
Mannitol 0.25-1g/kg 20%
Moderate hyperventilation
Barbituate coma
Decompressive cranectomy
DECRA
Reduced LOS on ICU
Increased chance of unfavourable outcome
RECUEicp
Lower mortaility
poor neurological outcomes
Stitch
medical therapy + delayed surgery vs early surgery
Significant reduction in mortaility
Bundles
VAP
Thromboprophylaxis
Early enteral feeding
Stress ulcer prophalaxis
Physiotherapy
Trials
SAFE
HIgher mortaility with albumin vs saline
CRASH
Higher mortaility with corticosteriods
CRASH 3
TXA may benefit some subgroups
LUND conscept
Volume targetted rather than ICP targetted
Reduction of stress response and cerebral energy demands
Reduction of capillary hydrostatic pressure
Maintenance of colliod osmotic pressure
Reduction in cerebral blood volume