TBI management

Hey all!

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.

Wow lots of question

*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?
phenylephrine is usually the first pressor we use.

Have you used a Hemedex monitor?
Never used or heard of hemex monitor

Do you use continuous EEG monitoring? Do you do spot EEGs?
The only time we use EEG is when someone is on a thiopental coma (to tirate for burst suppresions and when seizure is suspected)

Do you monitor ICP wire vs a ventric and what is your gold standard for ICP monitoring?
Our unit rarely uses a codman and almost 95% of the montiors are ventrics.

Do you follow TCDs (trans-cranial dopplers)?
At times we use TCDs with big SAH worried about vasospasms

When do you do a decompressive crani?
Usually decompressive crani happens pretty quick. Unless near the brain stem

At what pBO2 do you make vent adjustments?
We usually don't use pBO2 there is a study being done

Do you paralyze or barb them in prep for the swelling period?
paralyzing occurs when ICPs are high or if they anticipate there will be a lot of swelling. Usually with any brain injury we use 3% to help brain swelling

Where do you keep your patient's HCT level?
Only time HCT lvls are important is if they are doing HHH therapy for bad SAH in vasospasm

What drug(s) do you use for seizure prevention? If you use phenytoin or fosphenytoin do you monitor free dilantin levels?
Our unit currently uses keppra (levitricitam) to treat seizures. Great because there is no toxic level, but not great in monotherapy.

How cool do you keep your patients? What cooling system do you use? Do you have a shiver protocol?
Patient are usually kept 37.1. Currently the first line of shivering is demerol (other then that it is unclear on what they want to do for shivering)

What other drugs do you use on your patients (benzos vs pain meds vs amnesics, etc.)?
We usually are stingy on pain meds (usually morphine 2mg q 2 hours and oxycodone q 4).

What is your max on propofol and do you use it in light of propofol syndrome findings?
Usually the highest I go no propofol is 50mcg/kg/min. If it is that high and the patient is almost scrambling out of bed, if they have pain or other they went to the bathroom peopel get super strengh when they are uncomfortable!

Do you have a protocol for treating fevers?
-Our unit if fevers are problems there is an order for 650mg tylenol and we use cooling blankets. If fever does not respond we use a coolguard system (which is a centeral line that cools IV fluids) and paralyze the patient with cis.

Do you treat central fevers (fever not induced by infection, multiple cultures clear)? What drugs do you use for that?
we treat centeral fevers. Ususally same mannor as above.
How long before you respond to elevated ICPs?
- we wait for the ICP to hit 20. For 5 consecuative minutes. Then we will page doctor and there is immediate action.

Hope some of this helps. Currently I am going to head to work in 15 mins so I can only tell you this is how we do everything

Ok yeah thats a lot but I will respond just to the temperature management section. At the hospital I work at, we consider our patients febrile at 38.0. We are very agressive in our temperature management. At that point they start getting tylenol 650 mg q4 and probably a cooling blanket thrown on them, ice packs etc etc. If they don't respond to that, then we will insert a femoral coolguard cathetar to cool them. The lowest that we are cooling our TBI patients is to 35 degrees celcius (our fulminant liver failure pts are now getting cooled down to 33 degress... wow). Of course always watch your K levels when someone is being cooled this low so some resident doesn't come around and order to replace your pts K because when you reward them your K be WAY high.

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.

http://www.aann.org/pubs/guidelines.html

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.

Good luck!