TBI management

[MistyDawnRN06, BSN, RN]

Hey all! I'm posting this here as well as Neuro forum because if your hospital is like mine, we put TBIs in the SICU not the neuro unit.

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?

I'm interested in any information you might have!! Thanks!!!

[nrsang97, BSN, RN]

OK I didn't see this in the neuro ICU forum so I'll answer what I can here.

Our first line pressor is neo. We will use to keep CPP say 60-80.

What is hemedex?

We don't generally use continuous EEG's, but will occasionally get a eeg.

We monitor ICP with either ventric (integra) or camino bolt. Doc's preference.

TCD's aren't always routinely done.

Decompressive crani's are done quite frequently before they ever come to our unit.

pbTo2 levels are usually kept > 20-25. I had one the other night that we were recording levels of 5-8 pbto2 and no changes were made. We weren't sure if it was accurate due to the level of swelling.

For seizure prevention we use dilantin. We do free and total levels every few days and daily on some patients.

Sometimes we use a cooling blanket to cool. Other times we use the Alsius. Usually set for temp goal of 37. Temp is monitored through the bladder via foley with probe.

If they shiver we will occasionally give demerol. We also give mag for levels

As for meds we use propofol, but not all that often. We have paralyzed patients, and we generally use fentanyl and versed.

We do treat centeral fevers with tylenol and motrin.

We will call if ICP > 25 for 10minutes with no stim. Sometimes we have a standing order for mannitol.

We also use tons of hypertonic saline (3%) We will ride NA levels up to 160.

[MistyDawnRN06, BSN, RN]

Thanks for all the great info!

A hemedex monitor another bolt inserted that measures real-time tissue perfusion.

http://www.hemedex.com/

We have them available, but they're rarely used due to a political war in my hospital between services. They're a really great monitor when you can get them inserted.

[nrsang97, BSN, RN]

Have you used from Somanetics they are patches you can place on the forehead and occiput bilat. They measure oxygen saturations in the brain. We have used them as trials. Haven't used them otherwise.

http://www.somanetics.com/ this is their website.

This was originally designed for use in cardiac surgery paitnets and neo nates. There have been other trials as well with this. I don't know if any other hospital is using this. We aren't using it routinely, but it is interesting.