Neurosurgery notes/Trauma/Management of trauma/Non surgical

Non surgical

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Parent item
Management of trauma
Sub-item
Electrolyte
Post Traumatic Hypopituitarism (PTHP)
Temperature
Anaesthesia
PaO2 and PbtO2
Head injury ICP management
Seizure management
Coagulopathy
Infection
Nutrition
Steroids in non-surgical
Hyperventilation (HPV)
Anaemia
Blood pressure
Glucose

Goals of therapy

  • Keep ICP ≤22mm Hg (prevents “plateau waves” from compromising cerebral blood flow (CBF) and causing cerebral ischemia and/or brain death)
  • Keep CPP≥ 50mm Hg.
    • The primary goal is to control ICP; simultaneously, CPP should be supported by maintaining adequate MAP
      • No study shows any deleterious effect on ICP, morbidity or mortality as a result of normalizing intravascular volume or inducing systemic hypertension to achieve the desired CPP.

Threshold

BP

  • Berry, 2012: Maintaining SBP at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg or above for patients 15 to 49 or over 70 years old may be considered to decrease mortality and improve outcomes.

ICP

  • Sorrentino 2012 (Brain Trauma Foundation guideline):
    • ICP threshold
      • 22 mm Hg for ICP for reduced mortality
      • 18 mm Hg for favourable outcomes in women and older patients
    • CPP threshold
      • 70 mm Hg for mortality and favourable outcome
    • PRx threshold
      • 0.25 for reduced mortality
      • 0.05 for increase in favourable outcomes
    • ❌ Caution: patients can herniate even at ICP < 20 (depends on location of intracranial mass).
  • Better control may be possible by treating early rather than waiting and trying to control higher ICPs or when plateau waves occur.

CPP

  • The recommended target cerebral perfusion pressure (CPP) value for survival and favourable outcomes is between 60 and 70 mm Hg.
    • Sorrentino 2012 70
    • Allen 2014 >60
  • The threshold for ischemia is in the range of CPP<50–60mm Hg.
  • Avoiding aggressive attempts to maintain CPP above 70 mm Hg with fluids and pressors may be considered because of the risk of adult respiratory failure (ARDS).
  • Rather than a single threshold for CPP, it is likely that ‘optimal’ values can be identified at the individual level using multimodality neuromonitoring (Kirkman and Smith, 2014).

Brain oxygenation parameters treatment thresholds

  • Jugular venous O2 saturation < 50% OR
    • May be a threshold to avoid in order to reduce mortality and improve outcomes
  • Brain tissue oxygen tension (PbtO2) < 15mm Hg
  • It remains to be determined which interventions are useful to achieve this, and whether this improves outcome.