Questions and Answers
What is the main consequence of disruption of the blood-brain barrier in Traumatic Brain Injury?
Elevated intracranial pressure and poor neurologic outcomes
What is the goal of ICP management in Traumatic Brain Injury?
Maintain a CPP of 60-70 mmHg
What is the primary mechanism of action of Mannitol in reducing ICP?
Creating an osmotic gradient
What is a predictor of poor outcomes in Traumatic Brain Injury?
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What is the advantage of Hypertonic Saline over Mannitol?
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What is the recommended duration for seizure prophylaxis in Traumatic Brain Injury?
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What type of hemorrhage occurs between the dura and arachnoid mater?
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What is the primary goal of Hyperosmolar Therapy?
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What is a common adverse effect of Mannitol therapy?
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What is the most significant risk factor for early posttraumatic seizures within 7 days of injury?
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Which antiepileptic medication is commonly used for preventing seizures in TBI patients, despite having a lower safety profile?
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What is the recommended duration of antiepileptic therapy for TBI patients?
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Which of the following is NOT a predictor of DVT in TBI patients?
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What is the mechanism of action of Propofol in reducing ICP?
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What is a potential complication of Propofol infusion?
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When is Pentobarbital typically used in TBI patients?
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What is the benefit of Levetiracetam in TBI patients?
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What is the timing of VTE prophylaxis in TBI patients?
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Study Notes
Traumatic Brain Injury (TBI)
- Alteration in brain function or evidence of brain pathology caused by an external force
Types of Hemorrhage
- Extra-axial hemorrhage: Epidural hematoma (EDH), Subdural hematoma (SDH), Subarachnoid hemorrhage (SAH)
- Intra-axial hemorrhage: Diffuse axonal injury (DAI), Intraventricular hemorrhage (IVH), Intracerebral hemorrhage (ICH)
Primary and Secondary Injury
- Primary injury: Initial injury caused by external force
- Secondary injury: Result of subsequent cellular and molecular responses
Predictors of Poor Outcomes
- Elevated ICP
- Herniation
- Absent cough and gag reflexes
- Low GCS scores
- Over breathing the ventilator
Hyperosmolar Therapy
- Goals: Maintain cerebral perfusion pressure (CPP), provide adequate blood flow to brain
- CPP = MAP – ICP, Goal CPP: 60-70 mmHg, Goal ICP: < 22 mmHg
Mannitol and Hypertonic Saline
- Mannitol: Osmotic diuretic, decreases blood viscosity, increases microcirculatory flow
- Adverse effects: Hypernatremia, Hypovolemia, Renal dysfunction
- Hypertonic Saline: Increases MAP, decreases ICP, improves CPP
- Monitoring: serum sodium levels, renal function
- Adverse effects: Hypernatremia
Comparison of Mannitol and Hypertonic Saline
- ICP reduction onset: Mannitol < 5 min, Hypertonic Saline 15-30 min
- ICP reduction duration: Mannitol up to 12 hrs, Hypertonic Saline 1.5-6 hrs
- Rebound effect: Mannitol none, Hypertonic Saline possible
- Diuretic effect: Mannitol none, Hypertonic Saline yes, ↓MAP
Early Seizure Prophylaxis
- Recommended to prevent early post-traumatic seizures within 7 days of injury
- Risk factors: GCS < 10, Immediate seizures, Subdural, epidural, or intracerebral hematoma, Post-traumatic amnesia lasting longer than 30 mins, Cortical contusion, Linear or depressed skull fracture, Age < 65 years, Penetrating head injury, Chronic alcoholism
Antiepileptic Therapy
- Phenytoin: Most data to support its use, not used as often, Monitoring: dose titrated based on phenytoin levels, not as well tolerated as levetiracetam, more sedating
- Levetiracetam: Used more commonly, shown to be as effective as phenytoin in preventing seizures, benefits: improved safety profile, easy administration, few DDI, safe in pregnancy, no drug monitoring required, 1:1 IV to PO conversion
Duration of Therapy
- 7 days post TBI
VTE Prophylaxis
- Background: High risk for VTE due to hypercoagulable state from primary brain injury, periods of prolonged immobilization, focal motor deficits
- Predictors of DVT: Age, SAH, ISS > 15, Extremity injury
- Agents: Compression devices (SCDs), graduated compression stockings, LMWH or low-dose UFH
- Timing: LMWH or UFH within 24-48 hr from stable head CT
Other Agents
- Propofol: Sedative of choice in TBI patients, decreases ICP, rapid onset, short duration, possible neuroprotective effects, no mortality benefit, no effects on neurological improvement
- Monitoring: Triglyceride levels, Propofol related infusion syndrome (PRIS)
- Pentobarbital: Not a 1st line agent, elevated ICP refractory to other agents, barbiturate coma, concern
