Acute Management of Traumatic Brain Injury

Abstract

Synopsis Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. As the primary injury cannot be undone, management strategies must therefore focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow (CBF). Cerebral perfusion pressure can be maintained by increasing mean arterial pressure (MAP), decreasing intracranial pressure (ICP), or both. MAP can be increased through a combination of pressors in the euvolemic state, although the ideal fluid in TBI patients is unknown. The goal should be euvolemia and avoidance of hypotension. Elevated intracranial pressure can be treated through an algorithmic approach utilization simple bedside maneuvers, hyperosmolar therapy, cerebral spinal fluid (CSF) drainage as well as pentobarbital coma and decompressive craniectomy in refractory cases. Mass lesions may require operative evacuation depending on size, exam findings, and ICP measurements. Although CPP may not be an ideal surrogate for cerebral blood flow and metabolic delivery, other modalities have not gained widespread use due to paucity of strong data. Other factors that deserve important consideration in the acute management of TBI patients are venous thromboembolism, stress ulcer, and seizure prophylaxis as well as nutritional and metabolic optimization.

Acute Blood Pressure Management in Neurocritically Ill Patients

“…Based on this review, the authors concluded that SBP ranges from 120–150 mm Hg and MAP ranges from 85–110 mm Hg may be the thresholds to consider to improve functional outcomes. These higher SBP thresholds above 90 mm Hg have not been universally accepted, however, given the limited evidence to support such changes without clear functional outcome and mortality benefit …”

“…These higher SBP thresholds above 90 mm Hg have not been universally accepted, however, given the limited evidence to support such changes without clear functional outcome and mortality benefit. 52 Hypotension is commonly associated with ASCI due to a variety of pathophysiologic reasons including hypovolemia due to trauma or level of injury to the spinal cord and subsequent nerve innervation potentially affected. Abundant data on a target BP threshold when managing patients with ASCI are lacking.…”

Evolução da vítima com trauma cranioencefálico na sala de emergência

“…Estudos mostram PAS inicial no local das ocorrências <90 mmHg (hipotensão) em 4% dos indivíduos tratados por serviço médico de emergência, e a saturação periférica de oxigênio (SpO 2 ) <90% (hipóxia) foi documentada em 19% dos pacientes (2,22,11,32) . (12,28,33,34) . O exame primário desses pacientes deve incluir:…”

“…Vias aéreas e proteção da coluna cervical: assegurar que a via aérea esteja permeável, a fim de manter a oxigenação e prevenir a disfunção ventilatória, pois hipóxia e pressão arterial de oxigênio (PaO 2 ) ≤60 mmHg estão associadas a mortalidade em pacientes com TCE e, portanto, devem ser evitadas e corrigidas rapidamente. Como pacientes com TCE podem apresentar fratura de vértebras, sua coluna deve estar estabilizada e imobilizada (12,28,33,34) . (12,28,33,34) .…”

“…Como pacientes com TCE podem apresentar fratura de vértebras, sua coluna deve estar estabilizada e imobilizada (12,28,33,34) . (12,28,33,34) .…”