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Critical Care Mailbag – Isolated Head Trauma

Rob Orman, MD and Scott Weingart, MD
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13:55

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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01:25

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EM:RAP 2016 December Written Summary 910 KB - PDF

Scott Weingart walks through the acute management of an intubated patient with isolated head injury. His message: one of our primary focuses should be maintaining cerebral perfusion pressure.

Critical Care Mailbag - Isolated Head Trauma

Rob Orman MD and Scott Weingart MD

 

Take Home Points

       Hypotension in a patient with isolated head trauma is worrisome.

       Mannitol is a potent diuretic and fluid replacement should match urine output.

       Start norepinephrine or push-dose pressors immediately if there is hypotension.

       Propofol is a good option for sedation due to neuroprotective effects and despite associated hypotension, which may be managed with pressor support.

 

      A patient has isolated head trauma with hemorrhage. They do not need surgery immediately. The patient is intubated. The blood pressure is 90 systolic. What is your plan post intubation?

      Why is the patient hypotensive? The patient should be hypertensive. Usually the brain and neurovascular system are trying hard to increase perfusion to the brain. Often you are dealing with intractable hypertension. You should be concerned about hypotension.

      Hypotension from brain swelling does not usually occur until the point of herniation.

      Did the patient get mannitol? People often administer mannitol without realizing that it is a potent diuretic. You need to match the patient’s urine output to avoid hypotension.

      Did the patient get a lot of sedation for intubation? This can cause hypotension.

      Hypotension may sometimes be seen in aneurysmal subarachnoid hemorrhages due to the neurocardiogenic axis effects. This has been reported in other types of bleeds. Patients may develop cardiogenic shock or Takotsubo cardiomyopathy from the brain injury.

      Start norepinephrine or push-dose pressors immediately. Don’t just leave the patient hypotensive for 15-20 minutes while giving them fluids. We know that hypotension and malperfusion, especially in the first 24 hours, is incredibly harmful. You may be adversely affecting your patient’s outcome the longer you leave them hypotensive.

      Did you miss something? Is there a source of bleeding somewhere or neurogenic shock from a spinal injury?

      What is your target blood pressure? We don’t know the answer but in general a MAP of 80 is a reasonable target. This gives you a buffer for a cerebral perfusion pressure of 55-60 assuming an ICP of 20.

      Do you give fluid? If you have it available, you can give hypertonic saline. This may be 3% hypertonic saline or 1-2 amps of sodium bicarb which is 7% hypertonic saline. This will decrease the intracranial pressure and increase cardiac output. Give each amp over about 5 minutes.

      What should you use for sedation?

o      Although short acting agents are preferred to facilitate performing an exam, the exam is less important once they are intubated. It is incredibly important to perform a good exam prior to intubation.

o      You want a sedative that will also decrease the cerebral metabolic rate, oxygen requirements of the brain and ICP. Propofol is titratable and decreases the cerebral metabolic rate. If the propofol causes vasodilation and decreases the blood pressure, use pressors.

o      Try to avoid boluses of propofol as this can trigger large swings in the blood pressure. If you do have to give them a bolus, use a small bolus of 20mg at a time. Start at 20mcg/kg/min and titrate up. Make sure there isn’t a lot of dead space in the IV delaying delivery of the propofol.

 

      Weingart provides seizure prophylaxis with levetiracetam.  There is some suggestion levetiracetam may have worse cognitive outcomes compared to phenytoin but it is much easier to dose and does not require checking levels. These patients should not be on long-term anti-epileptics. In general, prophylaxis is not recommended in non-traumatic bleeds.

 

 

brendanC -

"If you have ICP issues, propofol and fentanyl

Hemodynamically Compromised Patients

Fentanyl and then,

Ketamine drip or intermittent boluses"

This is copy/paste from EMCRIT 2014. "analgesia first" was the message. I am assuming that the traumatic SDH/SAH who is intubated fits into the discussion. You seemed to have strayed from your long-time message about post-intubation care or did I miss something?

Dean B., M.D. -

Presumably, one would be starting fentanyl/propofol alongside a vasoactive medication in parallel?
This would allow the patient to be both comfortable & achieve a decent cerebral perfusion pressure.
I am curious as to whether Scott starts noradrenaline/norepinephrine peripherally or goes for epinephrine boluses via a peripheral IV?

Scott G. -

What about for the other end of the spectrum? A patient who is very hypertensive? Say systolic above 200. Is the blood pressure goal the same as atraumatic ICH? Or is the only BP requirement to keep the MAP above 80?

Joseph B. -

If the pathophysiology is Takutsubo then push dose EPI or norepinephrine infusion can worsen dynamic LVOT obstruction.

A systematic review by Nazir et al in International Journal of Cardiology (229, 67-70) also suggested an association between EPI and takotsubo. It makes sense to avoid further exogenous catecholamines in a disease precipitated by excess catecholamines.

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Pneumonia in the Hotseat Full episode audio for MD edition 227:49 min - 317 MB - M4AEM:RAP 2016 December Aussie Edition Australian 31:23 min - 43 MB - MP3EM:RAP 2016 December Spanish Edition Español 79:39 min - 109 MB - MP3EM:RAP 2016 December Canadian Edition Canadian 16:00 min - 18 MB - MP3EM:RAP 2016 December French Edition Français 30:18 min - 42 MB - MP3EM:RAP 2016 December German Edition Deutsche 94:18 min - 129 MB - MP3EM:RAP 2016 December Written Summary 910 KB - PDFEMRAP 2016 December MP3 Files 183 MB - ZIPEM:RAP 2016 December Board Review Answers 201 KB - PDFEM:RAP 2016 December Board Review Questions 193 KB - PDF

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