I'm trying to get my unit to step up TBI management. We need to take advantage of advances, but the MDs won't make a move without evidence based practice. If I can figure out what the gold standard of treatment is, I can find the research to back it up to present to them.
*Please tell me about your standards of TBI management. If you have any article/research links, I'd love to have them.
Currently, we do ventric/codman wire/licox, but we don't do early decompression. We wait until they have ICP problems to paralyze or barb them. We use Neo to maintain CPPs and Vaso to treat DI.
*What is your first line pressor? Have you used a Hemedex monitor? Do you use continuous EEG monitoring? Do you do spot EEGs? Do you monitor ICP wire vs a ventric and what is your gold standard for ICP monitoring? Do you follow TCDs (trans-cranial dopplers)? When do you do a decompressive crani? At what pBO2 do you make vent adjustments? Do you paralyze or barb them in prep for the swelling period? How are your TBI outcomes? Where do you keep your patient's HCT level? What drug(s) do you use for seizure prevention? If you use phenytoin or fosphenytoin do you monitor free dilantin levels? How cool do you keep your patients? What cooling system do you use? Do you have a shiver protocol? What other drugs do you use on your patients (benzos vs pain meds vs amnesics, etc.)? What is your max on propofol and do you use it in light of propofol syndrome findings? Do you have a protocol for treating fevers? Do you treat central fevers (fever not induced by infection, multiple cultures clear)? What drugs do you use for that? How long before you respond to elevated ICPs? What is your ICP threshold? Etc., etc.
I'm interested in any information you might have!! Thanks!!!
Quote from mistydawnrn06
...the mds won't make a move without evidence based practice.
what, your docs don't know how to do a literature search?
the aann has a clinical practice guideline on management of the patient with tbi.
click on the link. you'll be asked to answer a couple of question, then you can download the guideline free of charge
i used to love propofol, but i don't trust it anymore. it's meant for short-term use only, and too many times i've seen patients on it for several days who don't wake up for as many days after it's turned off. i prefer midazolam.
i used to see thorazine used to treat neurogenic hyperthermia, but haven't seen that used in many years. i use a cooling blanket. use a rectal temperature probe if you can get one - it will prevent a lot of grief. i've been told that you can prevent shivering by keeping the hands warm (cover them with socks), but i've never tried it myself.
i haven't put someone in a barb coma for many years. i remember one article a read within that last few years that said barb comas are considered a last-ditch effort. one thing i remember about keeping people in barb comas is to do meticulous mouth care - make sure you suction out the oropharynx and nasopharynx - otherwise the secretions pool and rot. h2o2 is your friend.
Last edit by aeauooo on Jan 18, '09